The smoking epidemic of the twentieth century has led to an increase in the incidence of chronic obstructive pulmonary disease (COPD), a largely preventable disease. The statistics concerning COPD have caused considerable alarm around the world. Globally, COPD is the fourth leading cause of mortality and the twelfth leading cause of disability. To address this growing problem, the World Health Organization partnered with the National Heart, Lung, and Blood Institute (NHLBI) to form a Global Initiative for Chronic Obstructive Lung Disease (GOLD). In 2001, they offered a global strategy to increase awareness of the disease and offer guidelines for disease prevention and treatment, referred to as the GOLD Guidelines. These guidelines and those created by leading medical societies are incorporated in this chapter.
Most patients are diagnosed with COPD in the sixth decade. Although it is an important chronic disease and a leading cause of disability in the elderly, it remains underrecognized. This chapter will focus on the early recognition and management of COPD, an important component of outpatient geriatric management.
GOLD defines COPD as partially reversible or nonreversible airflow limitation, which is progressive, and cannot be reversed by current therapies. In contrast asthma is defined as a syndrome characterized by reversible airflow limitation. Although GOLD definitions did not include traditionally used terminologies, such as chronic bronchitis and emphysema, these definitions are important to understand the disease spectrum. Chronic bronchitis is defined clinically as cough with sputum production for 3 months of a year for 2 consecutive years. Emphysema is a pathological diagnosis defined as the destruction of alveolar walls with accompanying enlargement of air spaces distal to the terminal bronchiole.
Key differences between COPD and asthma are that, in COPD there is (i) a lack of complete reversibility of airflow obstruction; (ii) neutrophil predominance in the airways, especially in the lumen; (iii) significant smoking history (usually >10 pack years) or exposure to burning biomass fuel, such as wood and manure; (iv) chronic colonization of bacterial organisms in the airways, especially in patients with severe disease; and (v) emphysematous changes in the lung parenchyma often associated clinically with reduced diffusing capacity on a gas diffusion test.
It is important to recognize that some of these distinctions become blurred in the elderly. Firstly, many elderly asthmatics, even those who have never smoked, have evidence of poorly reversible airflow obstruction, similar to COPD. This is caused by permanent remodeling of the airways. Secondly, bronchial hyperresponsiveness, an exaggerated bronchoconstrictive response to a given stimulus, is seen in a majority of middle-aged smokers with COPD and is a strong predictor of progressive decline in lung function. Thirdly, adults with asthma, especially those with severe disease, often demonstrate neutrophilia in their airways. Lastly and perhaps most importantly, many adult patients with asthma are current or former smokers. It is likely that such patients have more than one pathological process and several pathways of inflammation. These patients are likely to have ...