Practical management problems of stable chronic obstructive pulmonary disease in the elderly.
ABSTRACT Chronic obstructive pulmonary disease (COPD) is one of the most prevalent and increasing health problems in the elderly on a worldwide scale. The management of COPD in older patients presents practical diagnostic and treatment issues, which are reviewed with reference to the stable stage of the disease.
In the diagnostic approach of COPD in the elderly the use of spirometry is recommended, but both patient conditions (such as inability to correctly perform it due to fatigue, lack of coordination, and cognitive impairment) and metrics characteristics should be taken into account for the test performance. It has been demonstrated in population studies that the use of the fixed ratio determines a substantial overdiagnosis of COPD in the oldest patients. Other parameters have been suggested [such as the evaluation of Lower Limit of Normality (LLN) for the FEV1/FVC ratio], which may be useful to guide the diagnosis. Several nonpharmacologic - such as smoking cessation, vaccination, physical activity, and pulmonary rehabilitation, nutrition, and eventually invasive ventilation - and pharmacologic interventions have been shown to improve outcomes and have been reviewed. Effective management of COPD in older adults should always consider the ability of patients to properly use inhalers and the involvement of caregivers or family members as a useful support to care, especially when treating cognitively impaired patients. Especially in the older population, timely identification and treatment of comorbidities are also crucial, but evidence in this area is still lacking and clinical practice guidelines do not take comorbidities into account in their recommendations.
The Global Initiative for Obstructive Lung Disease has recommended criteria for diagnosis and management of COPD in the general population. On the contrary, available evidence suggests practical limitations in diagnostic approach and intervention strategies in older patients with stable COPD that need to be further studied for a translation into clinical practice guidelines.
SourceAvailable from: Enrico M CliniEuropean Respiratory Journal 12/2014; 44(6):1397-400. DOI:10.1183/09031936.00150814 · 7.13 Impact Factor
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ABSTRACT: The treatment of older and oldest old patients with COPD poses several problems and should be tailored to specific outcomes, such as physical functioning. Indeed, impaired homeostatic mechanisms, deteriorated physiological systems, and limited functional reserve mainly contribute to this complex scenario. Therefore, we reviewed the main difficulties in managing therapy for these patients and possible remedies. Inhaled long acting beta-agonists (LABA) and anticholinergics (LAMA) are the mainstay of therapy in stable COPD, but it should be considered that pharmacological response and safety profile may vary significantly in older patients with multimorbidity. Their association with inhaled corticosteroids is recommended only for patients with severe or very severe airflow limitation or with frequent exacerbations despite bronchodilator treatment. In hypoxemic patients, long-term oxygen therapy (LTOT) may improve not only general comfort and exercise tolerance, but also cognitive functions and sleep. Non-pharmacological interventions, including education, physical exercise, nutritional support, pulmonary rehabilitation and telemonitoring can importantly contribute to improve outcomes. Older patients with COPD should be systematically evaluated for the presence of risk factors for non-adherence, and the inhaler device should be chosen very carefully. Comorbidities, such as cardiovascular diseases, chronic kidney disease, osteoporosis, obesity, cognitive, visual and auditory impairment, may significantly affect treatment choices and should be scrutinized. Palliative care is of paramount importance in end-stage COPD. Finally, treatment of COPD exacerbations has been also reviewed. Therapeutic decisions should be founded on a careful assessment of cognitive and functional status, comorbidity, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics in order to minimize adverse drug events, drug-drug or drug-disease interactions, and non-adherence to treatment.
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ABSTRACT: This study aimed to evaluate the efficacy of comprehensive therapy based on traditional Chinese medicine (TCM) patterns on older patients with chronic obstructive pulmonary disease (COPD) through a four-center, open-label, randomized controlled trial. Patients were divided into the trial group treated using conventional western medicine and Bu-Fei Jian-Pi granules, Bu-Fei Yi-Shen granules, and Yi-Qi Zi-Shen granules based on TCM patterns respectively; and the control group treated using conventional western medicine. A total of 136 patients [Symbol: see text] 65 years completed the study, with 63 patients comprising the trial group and 73 comprising the control group. After the six-month treatment and the 12-month follow-up period, significant differences were observed between the trial and control groups in the following aspects: frequency of acute exacerbation (P [Symbol: see text] 0.040), duration of acute exacerbation (P = 0.034), symptoms (P [Symbol: see text] 0.034), 6-min walking distance (6MWD) (P [Symbol: see text] 0.039), dyspnea scale (P [Symbol: see text] 0.036); physical domain (P [Symbol: see text] 0.019), psychological domain (P [Symbol: see text] 0.033), social domain (P [Symbol: see text] 0.020), and environmental domain (P [Symbol: see text] 0.044) of the WHOQOL-BREF questionnaire; and daily living ability domain (P [Symbol: see text] 0.007), social activity domain (P [Symbol: see text] 0.018), depression symptoms domain (P [Symbol: see text] 0.025), and anxiety symptoms domain (P [Symbol: see text] 0.037) of the COPD-QOL. No differences were observed between the trial and control groups with regard to FVC, FEV1, and FEV1%.09/2014; DOI:10.1007/s11684-014-0360-0