Martin Connolly

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Respiratory disease is the second commonest cause of disability in old age [1], and chronic obstructive pulmonary disease (COPD) in turn is the commonest disabling respiratory condition in this age group. Estimates of the overall prevalence of COPD in the elderly population vary widely, from around 16% to nearly 30% [2-6]. These differences are likely to be largely dependent on differences in smoking prevalence, pollution levels, and poverty levels between subpopulations examined. Most epidemiological surveys, however, agree on the point that a large proportion of chronic obstructive pulmonary disease in old age remains undetected and untreated. A further complicating factor in epidemiological assessment is the accuracy of diagnostic labelling. Many elderly patients with chronic asthma and limited treatment responsiveness could equally well be (and often interchangeably are) labelled as either asthmatics or COPD sufferers. For the purpose of this chapter, chronic poorly responsive asthma in old age will be included under the COPD umbrella [7]. However, the historical lack of agreement in terminology has meant that medical practitioners often vary in diagnostic labelling, with a tendency to overdiagnose COPD in elderly men and overdiagnose asthma in young women [8].

There are several potent questions that should challenge physicians dealing with elderly COPD patients. This chapter does not claim to answer these questions comprehensively, merely to pose them and attempt an analysis.

Is COPD a different condition in old age?

This question has perhaps two main aspects: (i) is the disease aetiologically different?; and (ii) is the disease clinically different?

The answer to the first question must be in the widest sense a resounding 'no'. There is no evidence to suggest that cigarette smoking is not the major cause of COPD in the elderly. Indeed, smoking uptake reached its maximum in Britain in men born within 10 years of the turn of the 20 th century and in women born 20 years later [9]. It is these populations that have COPD and will continue for 20years or more to supply physicians with the majority of their (elderly) COPD patients. Whether the 'Dutch hypothesis' that an interaction between smoking and atopy may have a differential effect with ageing is an interesting question. Many studies have shown associations between lung function and measures of atopy in smokers and non-smokers [10-17], and have also shown that smokers have elevated atopic markers, particularly IgE levels [10-17]. Renwick and Connolly [18] have tentatively suggested that measures of atopy may be more strongly associated with both airways obstruction and bronchial hyperresponsiveness in older rather than younger adults. This is a surprising finding and contradictory to accepted wisdom concerning the decline of the atopic tendency with ageing.

More conventionally, however (as discussed above), the overlap between asthma and COPD is wider in the elderly than in the young, in large part because of the reduced treatment response [19] particularly to bronchodilators seen in elderly asthmatics, whether due to long duration of disease or even short duration of disease in more elderly individuals [8]. Whilst this may have limited practical import at present, with the clinical management of elderly subjects with stable 'COPD-like chronic asthma', these patients (and perhaps all elderly COPD patients, in view of the atopy-smoking interaction) should not be ignored as potential beneficiaries of new anti-asthma developments, such as leukotriene antagonists. This area, however, has no evidence base and needs research endeavour.

In terms of the clinical presentation of the condition, there is very good reason to argue that COPD may, for many elderly subjects at least, be a different condition to that seen in young sufferers. Whilst the insidious onset of the disease is well-recognized in all age groups, this is particularly so in old age. Predictive factors for various obstructive symptoms of cough, wheeze, sputum production and breathlessness are particularly low in old age [20]. Whether this reflects merely reduced expectation and activity level in the elderly, compounded by a reduced index of suspicion among carers and physicians, is unclear. There is evidence to suggest that the subjective perception of bron-choconstriction is impaired with increasing age [21,22]. The association of COPD with other disabling conditions (see below) is in many elderly patients a further confounding factor. Whatever the reasons, COPD is often not clinically detected at all in the elderly [6,23] or may be detected late, resulting in more likely progression to end-stage disease, with less opportunity for life-prolonging intervention. There is no justification in this regard for any therapeutic nihilism in terms of, for example, smoking cessation in old age—the motivated elderly smoker being just as likely to quit as a motivated young smoker [24,25], and with no age-related decline in the beneficial effects of nicotine replacement therapy [25,26].

The elderly patient with moderate or severe COPD will often present with a kaleidoscope of symptomatic, diagnostic and therapeutic characteristics, with impairments and disabilities influenced by a wide variety of factors both directly related and unrelated to COPD. In particular, the high incidence of depressive symptoms in COPD patients, including the elderly [27,28], and its effect on performance is a matter of great concern, particularly as depression is usually under-recognized in the elderly patient group [28]. The above argues for a specialist multidisciplinary team approach to the assessment of such patients, as it is only by use of the skills and facilities available to such a team that a full diagnostic and therapeutic package can be assembled.

How can perceived disabilities due to COPD be distinguished from those due to other age-related conditions?

The large number of septuagenarians and octogenarians completing marathon events across the world each year is striking evidence that ageing itself is not a cause of disability. Despite age-related reductions in performance of the cardiorespiratory and musculoskeletal system, the reserve of the human body is such that the mere addition of years in the span given to humans is not a major concern in terms of performance of normal activities of daily living. Impairment and disability at all ages has a clinical and pathological cause. As mentioned above, however, many elderly people may be affected by more than one age-associated condition. This is particularly true when there is a major aetiological factor (cigarette smoking) at play, often resulting in multiple-system disorder.

Clinicians and researchers attempt to quantify disability using scales that measure activities of daily living (ADL). In the context of COPD, some hospital-based ADL scales, particularly the Barthel Index [29], have ceiling effects that make them of little value [30]. ADL scales that measure more 'extended' community-based activity, such as the Nottingham Extended ADL Scale [31], are of more use. However, most ADL scales currently in use in geriatrics practice do not attempt to distinguish between respiratory-related disability and disability due to other conditions, and indeed most were designed to measure stroke-related disability. The Nottingham Extended ADL Scale, for example, though distinguishing well between elderly COPD sufferers and normals, is not responsive to COPD interventions [32]. Our own group has modified the Nottingham Extended ADL Scale to produce the Manchester Respiratory ADL Scale, which in addition to distinguishing elderly COPD subjects from normals is responsive to intervention by respiratory rehabilitation [32]. In clinical practice, however, the physician faced with a patient with multiple-system problems rarely has the luxury of treating each one in temporal isolation, and it may thus be individually difficult to estimate which element of any alleviation of disability is explained by treatments for separate conditions. There is some evidence to support the routine use of ADL scales in elderly COPD outpatients (see below). Furthermore, in the context of rehabilitation following acute admission for exacerbation of COPD, extrapolation of data on other conditions (particularly stroke) suggests that they have an important place. More research is needed in this general area.

What is the value of FEV1 in the elderly?

There are three separate questions here:

• Is forced expiratory volume in 1s (FEV1) in itself 'accurate' in old age?

• Is FEV1 useful for diagnosis?

• Is FEV1 useful for staging of disease?

In terms of the first question, it is clear that both FEV1 and FEV1/forced vital capacity (FVC) ratio are strongly related to gender and to age. Use of FEV1 expressed as percentage of predicted values does not remove the age bias completely because, as there is a positive relationship between FEV1 and height and a negative relationship between FEV1 and age, the use of predictive FEV1 increases the number of short and elderly individuals appearing to have abnormal results [33]. The use of FEV1 expressed as standardized residual (SR) has been advocated to remove such bias [33]. SRs should probably be employed in all research studies (particularly epidemiological studies) involving lung function measurements in old age, particularly when comparing elderly subjects to younger subjects.

However, this is almost certainly impractical in the clinical setting. Unfortunately, even after accepting the above, age-adjusted percentage predicted levels may be unreliable, as many of the normal populations employed to ascertain these values have not included elderly subjects and have mistakenly extrapolated above the age of 65, usually overestimating age-related decline in lung function. True age-related data up to the age of 85 have been supplied by the studies by Enright et al. [34], and these are probably the most suitable for clinical studies, at least in elderly Caucasian patients. In practice, many elderly patients with COPD find it difficult to complete an FVC manoeuvre, and thus although the FEV1/FVC ratio is in theory less affected by normal ageing, it is probably of less clinical value. In contrast to popular opinion, most elderly subjects are able to perform FEV1 manoeuvres satisfactorily.

In terms of diagnosis, formal lung function tests are if anything even more valuable in old age than in the relatively young. The multiplicity of system disorder and subsequent disability, together with the impaired perception of bronchoconstriction in old age [21,22], argues strongly for the use of objective lung function measures. Although peak flow may seem easier for many elderly patients to perform, its limited value in COPD is well recognized, and this is no less true in old age. There is increasing recognition that the use of FEV1 in epidemiological surveys both in the community and in hospital subpopulations detects previously undiscovered cases of COPD [6,35,36]. However, there is as yet no evidence to advocate the widespread use of lung function screening in populations or subpopulations of the elderly.

In terms of staging of disease in old age, the value of FEV1 is less clear. The British Thoracic Society Guidelines employ FEV1 in large part because of its prediction of mortality and its ability to at least roughly correlate with level of symptoms and intervention needed. It is however, well recognized even in younger subjects that the relationship between FEV1 and disability is poor, and this is if anything even more so in old age. Our own studies [30,37,38] have shown that FEV1 is not an independent predictor of quality of life in COPD, does not predict exercise capacity and predicts only 3% of the variance in disability as measured by an extended ADL scale.

Given that simple lung function tests are a poor measure of treatment response, how then is the latter to be assessed? Interest in recent years has focused on the use of quality of life (QoL) scales, both in terms of giving a holistic, patient-centred approach to treatment response and also (recognized more recently) a potentially more sensitive index of response. Any QoL scales contain a very large element of disability assessment, and thus in addition it would seem sensible and logical to have valid and responsive disability scales (ADL measures). This area has been discussed above; ADL scales, which have been widespread in geriatrics practice generally for many years, should perhaps be extended to COPD assessment, at least for elderly patients.

In our own studies [37], we have found the Breathing Problems Questionnaire [39] to be a particularly valid quality of life scale in old age and a better discriminatory tool than the Chronic Respiratory Disease Questionnaire [40]. Our studies were carried out in patients with a mean age of 78 years and a maximum age of 90years. Another QoL scale, The St George's Respiratory Questionnaire [41], has been shown to be valid (independent of age) in subjects up to the age of 75, and thus for research studies comparing elderly populations (particularly the young elderly) to younger populations, this is perhaps the best-validated tool.

In a clinical setting however, perhaps the main factors to consider when choosing a QoL questionnaire are: how long it takes to complete; what percentage of the variance in quality of life score can be explained by variance in other measurable parameters; and how responsive it is to intervention. In our hands, in elderly COPD subjects, 70% of the variance in Breathing Problems Questionnaire scores were explained by other measurable parameters, most importantly disability measure and a depression screening tool [30]. It is un clear, however, whether in a purely clinical setting both a disability measure (ADL scale) and a QoL tool need to be assessed. Disability measures have a greater track record in elderly patients generally, and this author would therefore advocate using ADL scales in clinical practice.

Are the same treatment algorithms applicable to the elderly?

The British Thoracic Society guidelines on the management of COPD [7] are a valuable tool, not least because they specifically addressed many of the problems that elderly patients with COPD face. The cornerstone of COPD management is smoking cessation, and the fact that the ability (or otherwise) of the elderly to quit is no less than that of younger smokers has already been addressed. On the more fundamental issue of whether it is worthwhile for an elderly subject to stop smoking, there are fewer data, but the benefits of quitting on the rate of decline in lung function, though lower in the elderly, are probably worthwhile up until about 80 years, especially in women [42]. Almost all data (in all age groups) on quit rates have been acquired in smokers motivated to quit, however. Though anecdotal evidence would suggest that such motivation falls with increasing age, there is no true evidence base here, and this area is worthy of study.

The only other currently proven life-prolonging treatment, long-term oxygen therapy (LTOT), has not been critically assessed in the very elderly, and indeed one of the major trials, the MRC LTOT trial, specifically excluded patients over the age of 70years [43]. However, clinical experience suggests that the elderly patient with incipient or current cor pulmonale is no less likely to benefit from LTOT than his or her younger counterpart. Though it is self-evident that the very elderly patient is unlikely to achieve the absolute prolongation in survival of a younger subject when using LTOT, there is need for research examining the other potential benefits, particularly the effect of adequate oxygenation on cognitive function and mood in old age.

The British Thoracic Society guidelines [7] specifically acknowledge that elderly patients may prefer to take inhaled b-adrenergic agonists on a regular basis rather than 'on demand'. This is at least in part in deference to the impaired perception of bronchoconstriction in old age [21]. In addition, although the bronchodilator response to both beta-agonists and ipratropium falls with age, the fall is less for ipratropium, emphasizing the potential added benefit of the use of muscarinic antagonist inhalers.

There is a wealth of literature on inhaler devices, and it is not with the scope of this chapter to discuss this topic further. Suffice it to say that there is good evidence in the elderly for the use of large-volume spacer devices (without the disadvantage seen in younger patients of poor patient acceptability), the Turbuhaler and the Autohaler.

Whilst theophyllines (and occasionally oral beta-agonist preparations) may be particularly useful in cognitively impaired elderly patients who are unable to use any form of inhaled bronchodilator, the side effects of theophylline are often prohibitive in the elderly, particularly as significant therapeutic benefit is only obtained at the upper end of the previously accepted 'therapeutic range' [44]. In practice, however, many elderly patients are taking regular theophyllines, and it is important to maintain a high index of clinical suspicion regarding side effects (particularly related to drug interactions) and to monitor serum levels regularly.

The prescription of nebulized bronchodilator therapy to the elderly should be made in accordance with published guidelines [45]. UK national guidelines currently caution against the use of high-dose beta-agonists in elderly patients with ischaemic heart disease and also suggest the use of mouthpieces rather than face masks in elderly patients with known or suspected glaucoma when using high doses of anticholinergic drugs. Particular emphasis should also be placed on whether the elderly patient can technically manage the nebulizer, and the help of carers may need to be recruited in this regard. The need for adequate follow-up and servicing cannot be overstressed. There may be a lower threshold for the use of nebulizers in elderly patients unable to manage standard inhalers. The use of oral corticosteroids should once again adhere to the British Thoracic Society guidelines on COPD management [7]. There is a particular concern about steroid-induced osteoporosis (or perhaps more accurately, steroid-exacerbated osteoporosis) in elderly patients, especially women. There is no indication for bone densitometry assessment prior to the use of oral corticosteroids in old age, as the vast majority of elderly persons will show osteoporotic indices in any case. However, the use of 'bone prophylaxis' is advisable, and the current recommendations of the British Osteoporosis Society are that calcium and vitamin D supplementation is acceptable in elderly patients receiving corticosteroids. This has the advantage of convenience and minimal side effects.

Particular attention in old age should be given to non-drug management. The uptake of influenza and pneumococcal vaccination is poor and as well as the standard methods of recruiting for this (in the community) an opportunistic policy should perhaps be pursued in hospital outpatients and even ward discharges. The dietary intake of frail and elderly patients in general is often limited whether or not they suffer COPD, often as a result of impaired ADL abilities. This clearly merits attention. Elderly patients as well as the young are able to benefit from pulmonary rehabilitation programmes [38] and should be included in them.

The high incidence of depression in elderly patients with COPD has already been mentioned [27,28], as has its under-recognition [28]. In these respects, COPD is little different from many other chronic disabling illnesses in the elderly, where the need for screening tests for depression is well recognized, the symptoms of the underlying disease often mimicking those of depression. Less well understood, however, are appropriate treatment strategies, and there is some evidence that elderly patients with depression associated with organic conditions will fail to accept a diagnosis of depression and decline antidepressant therapy when offered [46,47].

Management of acute exacerbations should once again follow the British Thoracic Society guidelines [7]. Perhaps the most important time in the hospital management of acute exacerbation in an elderly patient is the day or two prior to discharge, where particular emphasis should be given to discharge medication (particularly including inhaler technique) and a multidisciplinary assessment (sometimes requiring a home visit) of the patient's abilities to manage at home. The skills of the occupational therapist have so far been underused in the management of elderly patients with COPD.


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