Caring for the Older Person With Chronic Obstructive Pulmonary Disease

Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 09/2012; 308(12):1254-63. DOI: 10.1001/jama.2012.12422
Source: PubMed

ABSTRACT Chronic obstructive pulmonary disease (COPD), a common disease in elderly patients, is characterized by high symptom burden, health care utilization, mortality, and unmet needs of patients and caregivers. Respiratory failure and dyspnea may be exacerbated by heart failure, pulmonary embolism, and anxiety; by medication effects; and by other conditions, including deconditioning and malnutrition. Randomized controlled trials, which provide the strongest evidence for guideline recommendations, may underestimate the risk of adverse effects of interventions for older patients with COPD. The focus of guidelines on disease-modifying therapies may not address the full spectrum of patient and caregiver needs, particularly the high rates of bothersome symptoms, risk of functional and cognitive decline, and need for end-of-life care planning. Meeting the many needs of older patients with COPD and their families requires that clinicians supplement guideline-recommended care with treatment decision making that takes into account older persons' comorbid conditions, recognizes the trade-offs engendered by the increased risk of adverse events, focuses on symptom relief and function, and prepares patients and their loved ones for further declines in the patient's health and their end-of-life care. A case of COPD in an 81-year-old man hospitalized with severe dyspnea and respiratory failure highlights both the challenges in managing COPD in the elderly and the limitations in applying guidelines to geriatric patients.

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    ABSTRACT: To examine whether the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2013 revision offers greater predictive ability than the body mass index, airflow obstruction, dyspnea, and exacerbations (BODEx) index in elderly adults with chronic obstructive pulmonary disease (COPD). Prospective cohort study. University-affiliated medical center. Taiwanese outpatients with COPD (N = 354). Participants were classified as Group A (low risk with mild dyspnea), Group B (low risk with more-severe dyspnea), Group C (high risk with mild dyspnea), and Group D (high risk with more-severe dyspnea) for GOLD 2013 and from Quartile 1 (0-2 points) to 4 (7-9 points) for BODEx score. Ability to predict exacerbations and mortality was compared using logistic regression analysis with receiver operating characteristic (ROC) curve estimations and area under the ROC curve (AUC). Mortality was 14.1% for GOLD Group A, 14.5% for Group B, 6.5% for Group C, and 35.8% for Group D and 15.2% for BODEx Quartile 1, 22.5% for Quartile 2, 28.1% for Quartile 3, and 79.2% for Quartile 4. Risk of exacerbation relative to Group A was 1.7 (95% confidence interval (CI) = 0.6-4.3) for Group B, 14.1 (95% CI = 4.6-43.2) for Group C, and 17.9 (95% CI = 7.6-42.0) for Group D. The AUC for the GOLD classification and BODEx index were 0.65 and 0.67 for mortality (P = .60) and 0.79 and 0.73 for exacerbation (P = .03). The GOLD 2013 classification performed well in identifying individuals at risk of exacerbations, and its predictive ability for exacerbations was better than that of the BODEx index, although the predictive ability for mortality in elderly adults with COPD was poor for both indices. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.
    Journal of the American Geriatrics Society 02/2015; 63(2). DOI:10.1111/jgs.13258 · 4.22 Impact Factor
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    ABSTRACT: Objectives To evaluate whether a novel definition of spirometric respiratory impairment from the Global Lung Initiative (GLI) is strongly associated with respiratory symptoms and, in turn, frequently establishes symptomatic respiratory disease.DesignCross-sectional.SettingThird National Health and Nutrition Examination Survey.ParticipantsCommunity-dwelling individuals aged 40 to 80 (N = 7,115).MeasurementsGLI-defined spirometric respiratory impairment (airflow obstruction and restrictive pattern), dyspnea on exertion (DOE), chronic bronchitis (CB), and wheezing.ResultsPrevalence rates were 12.7% for airflow obstruction, 6.2% for restrictive pattern, 28.6% for DOE, 12.6% for CB, and 12.9% for wheezing. Airflow obstruction was associated with DOE (adjusted odds ratio (aOR) = 1.69, 95% confidence interval (CI) = 1.42–2.02), CB (aOR = 1.92, 95% CI = 1.62–2.29), and wheezing (aOR = 2.50, 95% CI = 2.08–3.00), and restrictive pattern was associated with DOE (aOR = 1.75, 95% CI = 1.36–2.25), CB (aOR = 1.39, 95% CI = 1.08–1.78), and wheezing (aOR = 1.53, 95% CI = 1.15–2.04). Nonetheless, among participants who had airflow obstruction and restrictive pattern, only a minority had DOE (38.6% and 45.5%), CB (23.3% and 15.9%), and wheezing (24.4% and 19.1%), yielding a positive predictive value (PPV) of only 53% for any respiratory symptom in the setting of any spirometric respiratory impairment. In addition, most participants who had DOE (73.0%), CB (67.8%), and wheezing (66.8%) did not have airflow obstruction or restrictive pattern, yielding a PPV of only 26% for any spirometric respiratory impairment in the setting of any respiratory symptom. The results differed only modestly when stratified according to age (40–64 vs 65–80).ConclusionGLI-defined spirometric respiratory impairment increased the likelihood of respiratory symptoms but was nonetheless a poor predictor of respiratory symptoms. Similarly, respiratory symptoms were poor predictors of GLI-defined spirometric respiratory impairment. Hence, a comprehensive assessment is needed when evaluating respiratory symptoms, even in the presence of spirometric respiratory impairment.
    Journal of the American Geriatrics Society 01/2015; DOI:10.1111/jgs.13242 · 4.22 Impact Factor
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