Chapter 84: Chronic Obstructive Pulmonary Disease

This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #26, #28

Learning Objectives

• Identify the most common clinical definitions of chronic obstructive pulmonary disease (COPD) and their limitations in older adults.

• Establish goals of care in older adults with COPD, most often directed at relieving symptoms, improving exercise tolerance and health status, reducing the risk of disease progression and exacerbations, as well as managing comorbidities.

• Define the palliative care needs of older adults with advanced COPD, including symptom burden and potential indications for referral to hospice.

Key Clinical Points

1. Age is a major risk factor for respiratory symptoms and the development of COPD due to age-related changes in lung physiology, and a greater exposure to COPD risk factors, particularly a higher prevalence of “ever smoking” in the older adult population.

2. Although symptoms consistent with COPD (eg, cough, hypersecretion of mucous) are common in seniors, two-thirds of persons who have symptoms of chronic bronchitis and half of those with physician-diagnosed emphysema/COPD have normal spirometry (ie, do not have COPD).

3. A reduced FEV₁/FVC establishes a diagnosis of airflow obstruction and limited reversibility is required to demonstrate chronic airflow obstruction, the hallmark of COPD. However, age-related airflow limitation is also characterized by a reduced FEV₁/FVC, and the threshold used to define COPD in seniors must account for normal aging.

   1. The most often used criteria for establishing and staging airflow obstruction are based on the Global Initiative for Obstructive Lung Disease (GOLD) criteria. The age-related limitations of the GOLD guidelines include two fundamental flaws: (1) GOLD defines a reduced FEV₁/FVC by a fixed ratio of 0.70, thus failing to distinguish between age-related airflow limitation and COPD-related airflow obstruction; (2) GOLD expresses the FEV₁ as a percentage of predicted value, thus failing to account for age-related variability in spirometric performance. The over-diagnosis of airflow obstruction (COPD) by GOLD in older adults is not associated with respiratory symptoms, exercise intolerance, impaired mobility, COPD hospitalization, or mortality.

   2. The Global Lung Initiative (GLI) has recommended the lower limit of normal be instead defined as the fifth percentile distribution of Z-scores (Z-score of –1.64), and use reference equations that include Americans and many other ethnicities (worldwide), as well as age range of up to 95 years. Prior work has shown that airflow obstruction defined by an FEV₁/FVC Z-score less than –1.64 is associated with respiratory symptoms, impaired mobility, frailty status, COPD hospitalization, and mortality.

4. Treatment of COPD in seniors is complicated by difficulty with drug administration (eg, due to cognitive impairment, physical disability) and may require additional teaching/coaching to achieve optimal outcomes.

5. Treatment of acute exacerbations includes:

   1. Intensified bronchodilator therapy.

   2. Corticosteroids should be considered for severe exacerbations, but side effects are common in seniors; for example, delirium is more common particularly at doses exceeding 60 mg daily.

   3. Antibiotics should be considered only for moderate or severe exacerbations, not mild episodes. Older adult residents ...