European Respiratory Society

Respiratory Diseases in the Elderly

Edited by V. Bellia and R. Antonelli Incalzi
Respiratory Diseases in the Elderly

On a global scale, average life expectancy is increasing and beginning to pose specific medical issues within the respiratory field as well as economical ones. This book aims to make the physician's approach to the elderly respiratory patient truly comprehensive, by arming them with the information necessary to help improve care procedures, further develop assessment and treatment protocols and give guidance on how to widen attention for the elderly patient beyond the immediate respiratory problem.

  • European Respiratory Society Monographs
  1. Page vii
  2. Page viii
  3. Page ix
  4. Page 1
    Abstract
    Correspondence: G. Viegi, National Research Council Institute of Clinical Physiology, Pulmonary Environmental Epidemiology Unit, Via Trieste, 41, 56126 Pisa39 050503596, Italy. E-mail: viegig@ifc.cnr.it

    Based on the world census, the number of adults aged ≥65 yrs has increased from ∼380 million in 1996 to ∼500 million (7% of total population) in 2008, with a projected increase to >700 million (16% of total population) by 2020.

    Increasing longevity can determine a rise in medical costs and an increase in demands for health services, since older people are typically more susceptible to chronic diseases. The elderly are also at greater risk of the effects of outdoor and indoor air pollution because of increased susceptibility and vulnerability. The present chapter explores the links between ageing and respiratory diseases and discusses the hypothesis that air pollution is more harmful to frail subjects, such as the elderly.

  5. Page 18
    Abstract
    Correspondence: R. Pistelli, Respiratory Physiology Unit, Complesso Integrato Columbus, Via Moscati 31, 00168 Roma39 063054641, Italy. E-mail: pneumologia@h-columbus.it

    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.

  6. Page 25
    Abstract
    Correspondence: P. Enright, University of Arizona, 4460 East Ina Road, Tucson, AZ 857181 5208447587, USA. E-mail: lungguy@aol.com

    Accurate and clinically useful spirometry can be performed successfully in >80% of patients aged >65 yrs. Using the forced expiratory volume in six seconds (FEV6) makes this easier. Spirometry is of clinical value for the detection and confirmation of chronic obstructive pulmonary disease (COPD) in older patients and for detecting poorly controlled asthma. However, there are many pitfalls to the interpretation of spirometric results in older patients, which often cause misclassification of airway obstruction or restriction of lung volumes.

    An FEV1/forced vital capacity of <0.70 should not be used to detect airway obstruction. Interpretation of mild restriction is of little clinical relevance. Normal spirometric results do not rule out asthma in a patient with intermittent respiratory symptoms. Bronchodilator responsiveness often does not help to distinguish asthma from COPD in a current or former smoker.

  7. Page 35
    Abstract
    Correspondence: R. Antonelli Incalzi, Campus Biomedico University, Via dei Compositori, 130, 00128 Rome39 0622541602, Italy. E-mail: r.antonelli@unicampus.it

    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.

  8. Page 56
    Abstract
    Correspondence: V. Bellia, Dept of Medicine, Pneumology, Physiology and Nutrition (DIMPEFINU), University of Palermo, Via Trabucco 180, 90146 Palermo39 0916882842, Italy. E-mail: v.bellia@unipa.it

    Although highly prevalent, asthma is under diagnosed and undertreated in the elderly. This is partly due to heterogeneous presentations. In particular, airway obstruction may modify its characteristics towards nonreversible features, possibly due to remodelling. Risk factors include age-related modifications affecting airway reactivity, atopy, tobacco smoking, environmental pollution and gastro-oesophageal reflux disease.

    Asthma in the elderly can be distinguished in terms of early or late onset, which identifies two distinctive patterns with clinical and therapeutic implications. The disease is associated with accelerated functional decline and increased risk of mortality. Clinical and functional characteristics of geriatric asthma may contribute to erroneous diagnosis of chronic obstructive pulmonary disease. However even long-standing asthma maintains a distinctive pathology.

    Comorbidities are frequent in such subjects and significantly influence their quality of life. In principle, treatment of asthma in the elderly does not differ from that of younger individuals; however, the response may be suboptimal. Bronchodilators are important but age-related impairment in responsiveness may limit their effectiveness. Inhaled anticholinergic drugs may represent a valid or adjunct alternative to β2-agonists.

    A peculiar problem is the underuse of inhaled corticosteroids probably connected to the fear for untoward effects. Careful attention should be paid to the adherence to therapy, particularly in subjects with comorbidities submitted to complex treatments.

  9. Page 77
    Abstract
    Correspondence: D.B. Coultas, The University of Texas Health Science Center at Tyler, 11937 US Highway 271, Tyler, TX 757081 9038775566, USA. E-mail: david.coultas@uthct.edu

    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.

  10. Page 90
    Abstract
    Correspondence: M. Miravitlles, Servei de Pneumologia, Hospital Clínic, Villarroel 170, 08036 Barcelona34 932275549, Spain. E-mail: marcm@clinic.ub.es

    Acute exacerbations are a frequent event in the progression of chronic bronchitis and chronic obstructive pulmonary disease (COPD) patients. Individuals with these conditions suffer a mean of 1–3 exacerbations·yr−1, some of which lead to hospital admission and may even be a cause of death. The importance of exacerbations of COPD has become increasingly apparent due to the impact these episodes have on the natural history of disease. It is now known that frequent exacerbations can adversely affect a patient’s health-related quality of life and short- and long-term pulmonary function. Costs associated with exacerbations are high, particularly due to relapses and admissions. Advanced age is a risk factor for frequent exacerbations and poor outcome in COPD.

    Bronchial infection is the main cause of exacerbations, but the problem in defining the microbial aetiology of a COPD exacerbation is that a great proportion of these patients have bacteria colonising their lower airways during the stable phase of the disease. However, some studies clearly suggest that the bacterial burden increases during exacerbations, and recent information shows that acquisition of a new strain of bacteria is associated with an increased risk of developing an exacerbation. Sputum purulence has proven useful in differentiating infectious from noninfectious exacerbations. Antibiotic treatment of exacerbations must take into account the microorganisms most likely to be the causative agents and their patterns of resistance.

    Optimising treatment for stable COPD helps to reduce exacerbations. Nonpharmacological interventions, such as rehabilitation, self-management plans and maintaining high levels of physical activity in daily life, are useful strategies for preventing exacerbations in elderly patients with COPD.

  11. Page 111
    Abstract
    Correspondence: V. Kaplan, Dept of Internal Medicine, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zürich41 12554445, Switzerland. E-mail: vladimir.kaplan@usz.ch

    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.

  12. Page 133
    Abstract
    Correspondence: M. Kikawada, Dept of Geriatric Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-002381 333422305, Japan. E-mail: kikawada@tokyo-med.ac.jp

    Elderly patients with cerebrovascular disease often have dysphagia that leads to an increased incidence of aspiration.

    It was previously reported that patients with silent cerebral infarction affecting the basal ganglia are more likely to suffer from subclinical aspiration and have an increased incidence of pneumonia. Basal ganglia infarction leads to the impairment of dopamine metabolism and a consequent decrease of substance P in the glossopharyngeal and sensory vagal nerves. Therefore, dysphagia and an impaired cough reflex may be induced by the decline of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical modulation of dopamine metabolism may improve swallowing and the cough reflex in patients with basal ganglia infarction.

    The main strategy for controlling aspiration and aspiration-related pulmonary infection in elderly patients is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. As aspiration pneumonia in elderly patients is related to various risk factors in addition to dysphagia and aspiration, effective preventive measures involve multiple approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and postural management.

  13. Page 142
    Abstract
    Correspondence: D.M. Mannino, Dept of Preventive Medicine and Environmental Health, University of Kentucky College of Public Health, 121 Washington Avenue, Lexington, KY 405361 8592572418, USA. E-mail: dmannino@uky.edu

    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.

  14. Page 150
    Abstract
    Correspondence: M. Selman, Instituto Nacional de Enfermedades Respiratorias, Tlalpan 4502, CP 14080, Mexico DF52 5556654623, Mexico. E-mail: mselmanl@yahoo.com.mx

    Interstitial lung diseases (ILDs) comprise a heterogeneous group of disorders that show similar clinical, radiographic and functional features. In many cases they also share a common final pathway characterised by the expansion of the fibroblast/myofibroblast population and increased extracellular matrix accumulation, leading to irreversible scarring of the lungs.

    Some of the ILDs are modified in elderly subjects (i.e. vasculitis), while other, primarily idiopathic pulmonary fibrosis are typical aging-related diseases.

    In the present chapter, the authors review the studies available regarding vasculitis in elderly subjects, and discuss the impact of comorbidities in the diagnosis and treatment of geriatric vasculitis.

    Potential pathways involved in the molecular pathogenesis of idiopathic pulmonary fibrosis as an aging-related disease are also examined.

  15. Page 163
    Abstract
    Correspondence: M. Righini, Division of Angiology and Hemostasis, Geneva University Hospital, 24, rue Micheli-du-Crest, 1211 Geneva 1441 223729299, Switzerland. E-mail: Marc.Righini@hcuge.ch

    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.

  16. Page 179
    Abstract
    Correspondence: M.R. Bonsignore, Dept of Medicine, Pneumology, Physiology and Nutrition, University of Palermo, Via Trabucco 180, 90146 Palermo39 0916882842, Italy. E-mail: marisa@ibim.cnr.it

    Sleep-disordered breathing (SDB) is common in the elderly, either in the general population or in series of patients with clinical suspicion of respiratory disorders during sleep or other common disease, such as heart failure, chronic obstructive pulmonary disease, diabetes or stroke. Despite the high prevalence of SDB, diagnostic criteria, clinical characteristics and treatment options are much less defined in the elderly compared with middle-aged patients. In addition, the occurrence of comorbidities further complicates the assessment of SDB outcomes in elderly patients. More studies are needed to address these issues, but a diagnosis of SDB in elderly subjects should not preclude treatment, as positive effects of therapy have been shown by several observational and controlled studies. Clinicians should be aware of the growing amount of data on SDB in the elderly, as ageing of the population will mean they are likely to encounter SDB increasingly often in this context.

  17. Page 205
    Abstract
    Correspondence: B. Cosio, Servei Respiratori. Hospital Universitari Son Dureta. C/ Andrea Doria 55, 07014 Palma de Mallorca, Balearic Islands34 971175228, Spain. E-mail: borja.cosio@ssib.es

    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.

  18. Page 217
    Abstract
    Correspondence: M. Guazzi, Cardiopulmonary Unit, University of Milano, San Paolo Hospital, Via A. di Rudinì, 8, 20142 Milan39 0250323144, Italy. E-mail: marco.guazzi@unimi.it

    Heart failure (HF) and diabetes mellitus (DM) promote a plethora of abnormalities in lung function and, in both conditions, the lung is considered the “target organ” for therapeutic interventions.

    HF is associated with changes in lung mechanics and gas diffusion, which are the direct consequence of haemodynamic perturbations and congestion. Changes in lung mechanics may vary according to the acute or chronic manifestations of HF, with a predominant obstructive lung pattern in acute HF and a restrictive one in chronic conditions.

    Specific relevance has recently been given to the anatomical and functional consequence of a pressure and/or a volume overload on the lung microcirculation of HF patients. This challenges the alveolar–capillary integrity, causes an increase in capillary permeability to water and ions, and impairs local mechanisms for gas diffusion. Remarkably, an impairment in alveolar gas conductance properties reflects underlying lung tissue damage, is involved in the pathogenesis of exercise limitation and is an independent prognostic marker.

    Diabetes mellitus elicits an angiopathy process of the lung microvessels that leads to the development of pulmonary dysfunction and to an accelerated organ ageing process. An increasing prevalence of type 2 diabetes mellitus with age indicates that elderly subjects are more exposed to the pulmonary complications of the disease. Diabetes mellitus could also contribute to an increase in the incidence of respiratory infections both by itself and by worsening the age-related abnormalities of the respiratory system. Epidemiological and clinical studies show that diabetes mellitus-related pulmonary involvement has important clinical and prognostic implications contributing to increased morbidity and mortality of older subjects.

  19. Page 240
    Abstract
    Correspondence: E.P.A. Rutten, Centre for Integrated Rehabilitation Organ failure, CIRO Horn, Postbus 4080, 6080 AB Haelen31 475587592, The Netherlands. E-mail: ericarutten@proteion.nl

    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.

  20. Page 256
    Abstract

    Frail elderly patients with asthma or chronic obstructive airways disease can benefit from inhaled drugs. Elderly people in good health can learn to use inhaler devices without difficulty. However, with advancing age, the prevalence of barriers to an effective inhaler technique rises, the most important of which are cognitive impairment and loss of manual dexterity.

    Research conducted in community and hospital settings has shown that inability to acquire an adequate inhaler technique can be predicted by tests of global cognition that are in widespread use, such as a Mini Mental State Examination score of <24 out of 30, and/or a score of <7 out of 10 on the Abbreviated Mental Test. Inability to copy overlapping pentagons, a quick test of ideo-motor praxis, is also strongly predictive.

    Patients with severe physical or cognitive impairments are readily recognised as being unable to self-medicate with inhalers, so they receive assistance from healthcare staff.

    Patients with moderate cognitive impairment are more easily overlooked and are more likely to be given an inhaler they are unable to use; it is in this group that cognitive tests have a role to identify patients who might need an alternative means of treatment, such as supervised use of an inhaler or nebuliser.

  21. Page 267
    Abstract
    Correspondence: P. Ernst, Division of Pulmonary Diseases, Jewish General Hospital, Pavillion G; room 203, 3755, Chemin de la Côte Ste. Catherine, Montreal, Quebec H3T 1E2, Canada. E-mail: pierre.ernst@mcgill.ca

    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.

  22. Page 286
    Abstract
    Correspondence: J-F. Muir, Pulmonary and Respiratory Intensive Care Dept, Rouen University Hospital and UPRES EA 3830 (IFR MP23), Institute for Biomedical Research, University of Rouen, 33 232889000, France. E-mail: Jean-Francois.Muir@chu-rouen.fr

    Noninvasive mechanical ventilation (NIV) was introduced into clinical practice during the 1980s, and rapidly emerged as the firstline treatment in patients with acute or chronic respiratory failure. At the same time, encouraging results were obtained in a study undertaken in the acute setting, which used NIV in patients with chronic respiratory failure.

    The growing importance of age, and the reluctance of older patients to be submitted to invasive ventilation, explains why this population is more and more frequently treated by NIV in acute and chronic conditions of respiratory failure.

    In the acute setting, NIV is preferred in the majority of cases, and is decided upon with the agreement of the patient and/or their relatives when it appears to be the most appropriate curative treatment for a patient who was in a previously acceptable general state of health. In all the cases, however, the decision to treat older patients in acute respiratory failure is related to the previous status of the patient and the level of comorbidities. Palliative noninvasive ventilation may be considered in such conditions.

    In patients with chronic respiratory failure, the patients with restrictive respiratory failure are the more responsive to noninvasive ventilation; the results remain controversial for obstructive lung diseases, such as as chronic obstructive pulmonary disease.

  23. Page 306
    Abstract
    Correspondence: C. Gridelli, Division of Medical Oncology, “S.G. Moscati” Hospital, Contrada Amoretta, 83100 Avellino, Italy. E-mail: cgridelli@libero.it

    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.

  24. Page 327
    Abstract
    Correspondence: D.M.G. Halpin, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW44 1392402828, UK. E-mail: david.halpin@rdeft.nhs.uk

    Death from a respiratory cause accounts for one in eight of all deaths in the European Union, yet palliative care has been a neglected aspect of the management of non-malignant respiratory disease. Care of the dying patient includes symptom control and psychological support with the aim of facilitating a “good death”. Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness.

    This article reviews the evidence base for palliative therapeutic approaches and other end-of-life issues, such as advance directives. It also considers general end-of-life issues, such as the importance of maintaining and supporting the patient's dignity, including their cultural and spiritual needs, dealing with place of death preference, and the need to provide support for families and carers before and after the patient's death. In addition, the article considers the evidence for and effectiveness of strategies for managing specific symptoms, including breathlessness, cough, pain, weight loss, muscle wasting, anxiety, depression, fatigue, malaise, weakness and delirium. The specific palliative care and end-of-life issues in chronic obstructive pulmonary disease, interstitial pulmonary fibrosis, lung cancer and mesothelioma are discussed.