Nicola A. Hanania, M.D., M.S.; Gulshan Sharma, M.D., M.P.H.; Amir Sharafkhaneh, M.D., Ph.D.

Disclosures

Semin Respir Crit Care Med. 2010;31(5):596-606. 

In This Article

Management Considerations for COPD in the Elderly

Management of Stable COPD

Over the last few years, several guidelines for the diagnosis and management of COPD have been introduced that emphasize the need for a multidisciplinary approach to the problem. The goals of therapy in the elderly with COPD are to treat and prevent chronic symptoms, decrease emergency room visits and hospitalizations, optimize and preserve activity level, and optimize pulmonary function with minimal adverse effect from medications. Management should also focus on improving health status (quality of life), which is greatly impaired by respiratory symptoms such as breathlessness and by symptoms of anxiety and depression. Furthermore, long-term goals include reduction in the decline of lung function over time and reducing mortality.

Nonpharmacological Interventions Smoking cessation is the most important, but often difficult to achieve, intervention. The approach to smoking cessation should include both behavioral interventions as well as pharmacotherapies that include nicotine-containing agents such as buproprion or varenicline.[36] Careful evaluation for adverse effects from these medications is very important, especially in the elderly. Other nonpharmacological therapies include maintaining adequate exercise and diet and avoiding secondhand smoke. All patients should receive annual influenza vaccine prophylaxis, and pneumococcal vaccine administration is also recommended. Pulmonary rehabilitation is an important intervention in patients who have severe exercise limitation despite adequate pharmacological intervention, especially for those patients who are motivated to participate in such programs.[34]

Pharmacological Therapies Currently available pharmacological therapies can improve symptoms and quality of life and decrease exacerbations. Long-acting bronchodilators are the initial treatment of choice in the majority of patients with mild to moderate disease. However, patients with severe disease and those with a history of recurrent exacerbations may benefit from treatment with inhaled corticosteroids (Table 5).[37] Oxygen therapy has been shown to improve survival and quality of life in patients with hypoxemia. A PaO2 level of <55 mm Hg on room air is generally accepted as an indication to initiate long-term oxygen therapy.

Elderly patients are at increased risk for adverse effects associated with COPD medications (Table 6), and there is increased potential for drug-drug interactions, especially in those who have extrapulmonary comorbidities. Care should be taken in the use of long-acting β-agonists in the elderly especially in underlying cardiac comorbidities. Patients treated with inhaled corticosteroids or inhaled corticosteroid (ICS)-containing combination therapies should have their bone mineral density monitored as well as regular eye exams. An increased risk of pneumonia has been recently reported with the use of ICS in patients with COPD. Short and long-acting inhaled anticholinergic medications should not be prescribed to patients with history bladder neck obstruction due to prostatic hypertrophy. The metabolism of theophylline is significantly reduced with advanced age and with presence of other comorbidities, and care should be taken in prescribing this medication in the elderly; systemic adverse effects may occur even if serum levels are within the therapeutic range.[38] Some medications used to treat common nonpulmonary disorders in the elderly may worsen COPD symptoms. Nonspecific β-blockers should be avoided, and angiotensin-converting enzyme (ACE) inhibitors may cause dry cough or worsen established COPD-associated symptoms of cough and should also be avoided or carefully monitored if used. Gastroesophageal reflux disease (GERD) is a common comorbidity and potential trigger of COPD symptoms, and it is often silent or causes subtle or minimal symptoms. If GERD is suspected, patients should be given adequate instructions to minimize its impact by elevating the head of their bed, avoiding certain food items that may exacerbate their reflux, and avoiding eating for at least 2 hours before retiring to bed. Additionally, most patients with GERD symptoms will benefit from empirical treatment with standard acid-suppression therapies.

Advanced age has been shown to be a significant predictor for poor adherence to pharmacological therapies. The complexity of prescription regimens (number and frequency of medications) coupled with memory loss and cognitive dysfunction that may be present in elderly patients can have a considerable impact on compliance with medications and adherence to other treatment recommendations. Mastering the technique required to successfully utilize an inhaled medication delivery device is a challenging problem in the elderly, and improper technique is very common, even in patients who have received detailed instruction in their use. To minimize this problem, every patient's metered dose inhaler (MDI) technique should be observed at every clinic visit, and patients should be reinstructed as needed. The use of the newer breath-actuated devices, including dry powder inhaler (DPI) devices, may help in optimizing the delivery of medications because these are generally easier for the elderly to use. However, most DPIs require the generation of adequate inspiratory flow to reach and disperse the medication in the lower respiratory tract. Because this ability may be considerably reduced in the elderly, especially for those with advanced disease, this issue should be considered when prescribing a DPI.[39] Furthermore, clinicians should always consider implementing different strategies to overcome some of the aforementioned barriers in the hope of achieving better compliance (Table 7). Patient education is an effective tool and should be an integral part in the management of COPD. It improves patients' skills and motivates them to gain better control of their disease. Clinicians should encourage open communications with their patients and define realistic goals of therapy to avoid noncompliance. Patients should be taught to recognize and avoid triggers, to recognize signs and symptoms of worsening COPD, and to seek medical help when needed. Whenever possible, all patients should recognize the rationale behind using the different medications, the correct way to use them, and their adverse effects.

Surgical Management Strategies Surgical therapies of COPD include lung volume reduction surgery (LVRS), bullectomy, and lung transplantation. However, these options are extremely invasive and may be associated with significant peri- and postoperative adverse outcomes in the elderly. LVRS can be performed through thoracoscopy or median sternotomy with the goal of resecting areas of the lung that are severely emphysematous and contribute little to lung function. In the National Emphysema Treatment Trial (NETT), LVRS was shown to have the potential to improve lung function, exercise tolerance, dyspnea, and quality of life. The LVRS group of patients who had upper lobe disease and low baseline exercise capacity had improved longevity when compared with the group that received optimal medical therapy. In an extensive analysis of NETT data for independent predictors of major pulmonary and/or cardiac morbidity after LVRS, advanced age was identified as one of the major risk factors for poor outcome.[40] In a study of nine patients older than 75 years who underwent LVRS, only three patients showed significant improvement. The remaining five patients had no clinical improvement after LVRS, and three of the five developed respiratory failure and failed to wean from the respirator.[41]

COPD patients with giant bullae (> hemithorax) may benefit from bullectomy with improvement in symptoms (dyspnea), lung function, oxygenation and ventilation, exercise capacity, and quality of life. In selected patients with advanced COPD, lung transplant may improve pulmonary function, exercise capacity, and quality of life. Similar to LVRS, the risks of complications and chronic respiratory failure are higher in the elderly, and most centers would not consider listing and transplantation for patients older than 65 years of age.[42]

Management of Acute COPD Exacerbations in the Elderly

The evaluation of patients during exacerbations should seek to determine the severity of COPD, identify comorbid medical conditions, and elicit a history of prior exacerbations and their outcomes, including hospitalizations and intubations.[34] In addition, the effect of the exacerbation on respiratory and hemodynamic function should be quantitated to facilitate severity classifications. Evaluation of oxygenation and ventilation will help to gauge the severity and guide the therapy. For treatment purposes, the severity of an exacerbation may be categorized as level I (ambulatory), level II (requiring hospitalization), and level III (acute respiratory failure).[34] The pharmacotherapy of exacerbations should include escalation of bronchodilator therapy, a short course of antibiotics, and systemic corticosteroids. In a large cohort of elderly patients hospitalized with COPD exacerbations, the majority had not been given antibiotics in the outpatient setting.[43] Patients admitted to the hospital with impending respiratory failure can be managed successfully with noninvasive ventilation; however, intubation and mechanical ventilation are often needed in patients with severe respiratory failure.

Antibiotic therapy is recommended for those patients who have at least two of the three major symptoms of worsening dyspnea, increased sputum production, and sputum purulence. First-line antibiotic agents include macrolides, doxycycline, or cephalosporins. However, fluoroquinolones or amoxicillin/clavulanate are recommended in cases of treatment failure.[34,35] Special attention should be given to more resistant bacteria such as Pseudomonas spp. in level III patients, and combination antibiotics should be considered for these patients.[35] Systemic corticosteroids reduce treatment failure and length of hospital stay and improve FEV1, but side effects such hyperglycemia are associated with their use. The issue of systemic side effects is of particular importance in elderly patients for the various reasons already discussed. According to ATS/ERS guidelines, systemic steroids at a dose of 40 to 60 mg daily for 10 to 14 days are recommended for management of exacerbations. The prognosis of patients hospitalized with an AECOPD exacerbation is poor in terms of survival and the effects of an exacerbation on postdischarge health-related quality of life. If advanced care planning has not occurred in the outpatient setting, discussions regarding the appropriateness of life-sustaining measures should take place during the hospitalization for an acute exacerbation (further discussion follows).

End of Life Issues and Palliative Care

Current treatment for COPD is of modest benefit in relieving symptoms, and patients will generally have significantly impaired quality of life despite therapy. Patients with advanced COPD are as likely as lung cancer patients to decline intubation or cardiopulmonary resuscitation (CPR), yet they are more likely to die in the intensive care unit (ICU) while receiving mechanical ventilation as compared with patients with lung cancer.[44] [45] One of the challenges for clinicians is the inability to predict the short-term survival for patients with COPD. Despite this uncertainty, patients with higher likelihood of death should benefit from end-of-life care discussions.[46] Such patients may be identified if they have two or more of the following: age >70 years, comorbidities, declining functional status, FEV1 < 30% predicted, oxygen dependence, prior hospitalization with COPD exacerbation, left heart failure, weight loss, and need for assistance with daily activities. Clinicians should use these criteria as a guide to initiate a dialogue with their patients concerning end-of-life issues. Despite the need for such a discussion, the majority of patients with moderate to severe COPD have not discussed end-of-life preferences with their physicians,[47,48] and most patients believe that their physicians are not aware of their preferences concerning end-of-life care.[48] Because the presence of two or more comorbidities as already described predict a higher likelihood of poor outcome if patients are admitted to the ICU and placed on mechanical ventilation, increasing efforts should be made to improve communication with patients and discuss these issues with such patients. Ideally, a discussion concerning palliative care should start early in the course of the disease to provide patient-centered, high-quality palliative care that is congruent with patient wishes as the disease progresses. It should be recognized that anxiety and depression are common in patients with COPD and can influence decision making, and untreated depression can have a significant impact on end-of-life care preferences.[49] Therefore, symptoms of anxiety and depression should be recognized and treated prior to end-of-life discussions.

Patients are generally amenable to a discussion with their physician concerning their diagnosis and disease process, treatment options, prognosis, what dying is like, and advance care planning.[50] Decisions should take into consideration the patient's spiritual or religious beliefs.[47] Patient preferences can change over time and in the context of clinical settings (outpatient vs hospital setting with acute exacerbations). Most end-of-life care discussions occur in the ICU during acute exacerbations and may influence patient preferences.[51] Thus advance directives can be useful in patients with moderate to severe disease in view of the unpredictable trajectory of their illness.[52] The somewhat unpredictable trajectory of COPD progression combined with periods of relatively clinical stability interspersed with acute exacerbation episodes does not fit the hospice philosophy very well, and such patients are often denied hospice. Families should be made aware of potential palliative services, which can be rendered at home. Noninvasive ventilation has been used as a palliative modality in patients who choose not to receive invasive ventilation. However, data to support its use are somewhat lacking.[53]

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