How to Manage COPD in Elderly?
Chronic Obstructive Pulmonary Disease (COPD), a common illness in the elderly, is a major cause of chronic morbidity and mortality. COPD is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response to the presence of noxious particles or gases in the airways and lungs. Exacerbations and comorbidities contribute to the overall severity in individual patients.
COPD is common in older people, with an estimated prevalence of 10% in population aged ≥75 years. Inhaled medications are the cornerstone of treatment for COPD and are typically administered by one of three types of devices, i.e. pressurized metered dose inhalers, dry powder inhalers, and nebulizers. However, age-related pulmonary changes may negatively influence the delivery of inhaled medications to the small airways. Also, physical and cognitive impairment, which are common in elders with COPD, pose special challenges to the use of handheld inhalers in the elderly. Health care providers must take time to train patients to use handheld inhalers and must also check that patients are using them correctly on a regular basis. Nebulizers should be considered for patients unable to use handheld inhalers properly.
COPD causes progressive damage to a person’s lungs. The airways of the lungs become obstructed, making it hard to breathe. Dying of COPD is dying of shortness of breath, one breath at a time. The rest of the body wears out. In other words, COPD can lead to other comorbid conditions such as heart disease.
Causes COPD in Elderly
The main cause of COPD is tobacco smoking. COPD often occurs in people exposed to fumes from burning fuel for cooking and heating in poorly ventilated homes. Only about 20 to 30 percent of chronic smokers may develop clinically apparent COPD, although many smokers with long smoking histories may develop reduced lung function. Some smokers develop less common lung conditions. They may be misdiagnosed as having COPD until a more thorough evaluation is performed.
How lungs are affected? Air travels down your windpipe and into your lungs through two large tubes. Inside your lungs, these tubes divide many times like the branches of a tree, into many smaller tubes that end in clusters of tiny air sacs. The air sacs have very thin walls full of tiny blood vessels. The oxygen in the air you inhale passes into these blood vessels and enters your bloodstream. At the same time, carbon dioxide i.e. a gas that is a waste product of metabolism, is exhaled. Your lungs rely on the natural elasticity of the bronchial tubes and air sacs to force air out of your body. COPD causes them to lose their elasticity and over expand, which leaves some air trapped in your lungs when you exhale.
Causes of airway obstruction include:
- Emphysema - This lung disease causes destruction of the fragile walls and elastic fibers of the alveoli. Small airways collapse when you exhale, impairing airflow out of your lungs.
- Chronic bronchitis - In this condition, your bronchial tubes become inflamed and narrowed and your lungs produce more mucus, which can further block the narrowed tubes. You develop a chronic cough trying to clear your airways.
In the vast majority of cases, the lung damage that leads to COPD is caused by long-term cigarette smoking. But there are likely other factors at play in the development of COPD, such as a genetic susceptibility to the disease, because only about 20 to 30 percent of smokers may develop COPD. Other irritants can cause COPD, including cigar smoke, secondhand smoke, pipe smoke, air pollution and workplace exposure to dust, smoke or fumes.
In about 1 percent of people with COPD, the disease results from a genetic disorder that causes low levels of a protein called alpha-1-antitrypsin. Alpha-1-antitrypsin (AAt) is made in the liver and secreted into the bloodstream to help protect the lungs. Alpha-1-antitrypsin deficiency can affect the liver as well as the lungs. Damage to the lung can occur in infants and children, not only adults with long smoking histories.
For elders with COPD related to AAt deficiency, treatment options include those used for people with more-common types of COPD. Some people can be treated by replacing the missing AAt protein, which may prevent further damage to the lungs.
Complications caused by COPD in Elderly
COPD can cause many complications, including:
- Respiratory infections - Elders with COPD are more likely to catch colds, the flu and pneumonia. Any respiratory infection can make it much more difficult to breathe and could cause further damage to lung tissue. An annual flu vaccination and regular vaccination against pneumococcal pneumonia can prevent some infections.
- Heart problems - COPD can increase your risk of heart disease, including heart attack. Quitting smoking may reduce this risk.
- Lung cancer - Elders with COPD have a higher risk of developing lung cancer. Quitting smoking may reduce this risk.
- High blood pressure in lung arteries - COPD may cause high blood pressure in the arteries that bring blood to your lungs.
- Depression - Difficulty breathing can keep you from doing activities that you enjoy. And dealing with serious illness can contribute to development of depression. Talk to your doctor if you feel sad or helpless or think that you may be experiencing depression.
Symptoms of COPD in Elderly
Often elders with COPD will blame their symptoms on age or the side effects of smoking. Most often, people are not diagnosed with COPD until they have lost 50 percent of their lung function. We were blessed with having two lungs and also an incredible compensation mechanism in our bodies. A person can lose up to 50 percent or less of lung function for any reason and compensate. If your loved one suffers from any of the following symptoms, a doctor’s visit may be required:
- Shortness of Breath - At first, a person may get tired upon strenuous exertion, say while walking up a long flight of stairs. Later, a simple task such as a trip to the mailbox causes breathlessness.
- Inability to Keep Up - Simple activities such as bathing and dressing may leave someone with COPD winded and exhausted.
- Chronic Cough - The patient may begin coughing once in a while and progress to coughing all the time.
- Sputum Production - Sputum or phlegm may be raised during coughing bouts.
- Wheezing and Chest Tightness - These are common symptoms of more severe COPD.
- Loss of Appetite and Weight Loss - Eating is difficult when a person is short of breath.
- Fatigue - This can be caused by a person fighting to breathe, or by a person’s body receiving less oxygen due to COPD.
Preventive Measures for COPD in Elderly
Unlike some diseases, COPD has a clear path of prevention. The majority of cases are directly related to cigarette smoking, and the best way to prevent COPD is to never smoke or to stop smoking now.
If you're a longtime smoker, these simple statements may not seem so simple, especially if you have tried quitting once, twice or many times before. But keep trying to quit. It's critical to find a tobacco cessation program that can help you quit for good. It's your best chance for preventing damage to your lungs.
Occupational exposure to chemical fumes and dust is another risk factor for COPD. If you work with this type of lung irritant, talk to your supervisor about the best ways to protect yourself, such as using respiratory protective equipment.
Treatment for COPD in Elderly
The treatment for COPD is palliative, not curative. It is probable that longevity cannot be significantly improved with any treatment, except in patients with hypoxemia who benefit from supplemental oxygen therapy.
Smoking Cessation - Smoking cessation, including cigarettes, cigars, and pipes, is the most important step in the treatment of COPD, since smoking is the most common cause. Smoking cessation can revert the decline in lung function to values of nonsmokers. In fact, an aggressive smoking intervention program has been shown to significantly reduce the age-related decline in FEV1 in middle-aged smokers with mild airway obstruction. Continuation of smoking essentially ensures that symptoms will worsen. Pharmacists have a huge opportunity for counseling in the smoking cessation arena with prescription and OTC medication intervention and patient education.
Pharmacologic Interventions - Medication intervention usually consists of life-long chronic therapy with dosage adjustments and additional agents when exacerbations present. Bronchodilators (oral or inhaled) are central to the symptomatic management of COPD. Additional treatment includes antibiotics, oxygen therapy, and systemic glucocorticosteroids. Inhaled glucocorticosteroids continue to be studied.
Chronic systemic steroid treatment poses the risk of serious side effects and is therefore usually reserved for acute exacerbations. Elders with COPD should receive pneumonia and influenza vaccines. Lung transplantation or lung volume reduction surgery may be an option for certain individuals. In addition, treatments for alpha-1 antitrypsin (AAT) deficiency emphysema, including AAT replacement therapy (a life-long process) and gene therapy, are being evaluated.
A comprehensive pulmonary rehabilitation (PR) program may lead to significant clinical improvement by increasing exercise tolerance and reducing shortness of breath. PR programs may even reduce the number of hospitalizations, although to a lesser extent. It should be noted that while PR programs are aimed at improving independence and improving quality of life, they do not improve lung function or prolong survival.
Ideally, a variety of health care professionals are required to deliver the wide range of services offered in a comprehensive PR program. Educating patients about their disease is a key component.
Exercise training, often with oxygen, may take place at the home or in a clinic setting and often includes stationary bicycling, stair climbing, and walking to improve leg strength, plus weight lifting to improve arm strength.
Techniques are taught to decrease shortness of breath during exercise and sexual activity. Additionally, patient evaluation and goal setting, nutritional evaluation and counseling, psychosocial counseling and the coordination of complex medical services are also provided.
Medication counseling is an important and integral part of PR, since medication non-adherence is a serious complicating factor in COPD management.
Education regarding the appropriate dosing and timing of regularly scheduled and as-needed medications, the proper technique for self-administering inhaled medications, ongoing monitoring, and information for family members and caregivers is imperative.