- •COPD is highly prevalent, but it frequently remains unrecognized in the elderly.
- •A relevant proportion of elderly people cannot perform a satisfactory spirometry.
- •COPD dramatically impacts health status of elderly patients.
- •Comorbidity has a major prognostic role but frequently remains unrecognized.
- •Recommendations coming from clinical trials only partly apply to the elderly.
- •The internists should aim at providing a truly comprehensive and effective treatment.
1. Clinical vignette
2. Is Chronic Obstructive Pulmonary Disease (COPD) an age-related chronic condition?
|Country||COPD prevalence||Reference population||Data source||Year|
|Austria||4.6%||Adult population sample||Statistik Austria||2007|
|Belgium||5.3%||Middle-aged population||Ministry of Health. Health for all database||2004|
|Czech Republic||2.4%||Adult population||Institute of Health — Information and Statistics||2007|
|Finland||Over 5% have diagnosed COPD; a further 5% estimated to have concealed COPD||Total population||The National Finnish COPD Programme||2007|
|France||6% to 8%||Adult population||Ministère de la Santè et des Solidaritès||2005|
|Germany||13.2%||Adult population||Geldmacher et al. (BOLD study) |
|Ireland||7.3%||Adult population||The Irish Thoracic Society||2008|
|Netherlands||2%||Estimated||National Institute for Public Health and the Environment||2006|
|Portugal||4.6%||Adult population||National Observatory of respiratory disease||2008|
|Serbia||6.0%||Adult population||Institute of Public Health of Belgrade||2007|
|United Kingdom||1.5% correctly diagnosed; 3.7 million (6%) estimated to be affected||Population over 40 years old||Stang et al. |
3. Why COPD is often so difficult to diagnose in the elderly population?
|Patient related conditions|
|• Motor and sensory deficits, e.g. pyramidal or extra-pyramidal disorders|
– Lack of dexterity and poor control of ventilation during spirometry;
– Difficulty in coordination and properly sequencing the flow volume maneuver and the breath holding.
• Dementia or cognitive impairment: deteriorated constructive functions, verbal attainment and, mainly, secondary verbal memory
– Difficulty in learning and recall instruction to perform spirometry
– Poor ability to interact with the technician or physician
• Mood depression and psychological factors
– Poor motivation, early discouragement for unsuccessful trials.
• Educational level
– Ability to understand technical instructions
• Malnutrition/undernutrition, deconditioning: respiratory muscles weakness
– Difficulty in providing acceptable and reproducible tests
|Environment and technician related conditions|
|• Poor geriatric expertise of the physician or technician|
– She/he is unable to teach the patient through a variety of non-verbal tools, like visual examples or touch-guided respiratory maneuver.
– She/he does not motivate the proband by stressing any, even minimal, improvement, and does not tailor the teaching process to the individual learning potential.
• Unpleasant or stressful environment
– The diagnostic test does not fit the age-related slowing of learning process and, then, the need for gently repeated or even fractioned maneuvers.
|Acceptability criteria |
|Quality control||Limiting factors in elderly|
|Good start (no hesitation to begin the maneuver)||• Extrapolated volume is <5% of FVC or 0.15 L, whichever is greater or|
• Time to PEF is <120 ms (optional until further information is available)
|• Motor and sensory deficit|
• Respiratory muscle weakness
|Satisfactory and complete exhalation||• 6 s of exhalation and/or a plateau in the volume–time curve or|
• Reasonable duration or a 1-second plateau in the volume–time curve or
• The subject cannot or should not continue to exhale
|• Severe air trapping or airway obstruction|
• Restrictive lung disease
• Poor motivation
• Expiratory dyspnea
|Absence of artifacts||• Cough or glottis closure during the first second of exhalation|
• Early termination or cutoff
• Variable effort
• Obstructed mouthpiece
|• Difficulty on learning and recall instruction to perform spirometry|
• Poor ability to interact with the technician
|At least three acceptable spirograms satisfying repeatability quality control criteria||• Two largest FVCs within 0.2 L of each other|
• Two largest FEV1s within 0.2 L of each other
|• Respiratory muscles weakness or poor endurance|
• Physical unfitness and deconditioning
• Poor motivation
- Incalzi R.A.
- Pennazza G.
- Scarlata S.
- Santonico M.
- Petriaggi M.
- Chiurco D.
- et al.
- Incalzi R.A.
- Pennazza G.
- Scarlata S.
- Santonico M.
- Petriaggi M.
- Chiurco D.
- et al.
|Lung cancer||Results widely depend on the different sensor system used. Quartz microbalances currently show the best diagnostic accuracy around 90%. Sensitivity and specificity range from 70 to 90% |
|Asthma||The sensor system was able to separate mild asthmatics from controls, and moderate to severe asthmatics from controls, but not mild and moderate from severe asthmatic groups |
|COPD||Breath fingerprint was highly sensitive and specific in discriminating COPD patients from controls |
, hypoxemic from non-hypoxemic COPD
and COPD from asthma
|Interstitial lung disease||Exhaled ethane seems a valuable indicator of disease activity and prognosis for ILDs |
|Tuberculosis and other lung infections||The system was 89% sensitive and 91% specific at identifying M. tuberculosis |
. It was also able to differentiate several in-vitro gram + and gram − bacteria
. E-nose fingerprints correctly classified 77% of the BAL samples, with and without microbiological growth, from ventilated patients not on antibiotics. Inclusion of patients on antibiotics resulted in 68% correct classification. Seventy percent of isolates were accurately discriminated into four clinically significant groups
|History||Respiratory function tests||Supportive elements|
|H1. Recurrent wheeze||R1. Positive methacholine test||S1. Early onset (in adolescence or young adulthood)|
|H2. Nocturnal wheeze||R2. Completely reversible bronchial obstruction||S2. History of atopy|
|H3. Dry cough (variant clinical presentation)||R3. Partially reversible bronchial obstruction||S3. Triggers identified|
|S4. Sputum eosinophilia|
|S5. Steroid dependence|
|S6. Normal DLCO|
4. How does COPD impact health status in old patients?
- Antonelli Incalzi R.
- Pedone C.
- Pahor M.
- Anzueto A.
5. What's about the prognosis of COPD?
|Con-causal: sharing risk factors, mainly smoke||Coexisting in the absence of shared risk factors, except for age||Complicating COPD|
|Atherosclerotic disease: coronary, cerebral, lower limbs||Glaucoma||Anxiety/depression|
|Chronic renal failure||Cognitive impairment|
|Lung cancer||Diabetes mellitus||Osteoporosis|
|Congestive heart failure||Benign prostatic hypertrophy||Sarcopenia|
|Aortic aneurysm||Degenerative joint disease||Arrhytmias|
|Pulmonary fibrosis (respiratory bronchiolitis–interstitial lung disease)||Obstructive sleep apnea||Pulmonary embolism|
6. Which are the main therapeutic problems in elderly COPD patients and which evidences are still lacking in this population?
- 1)The source of information from pharmacological trials is intrinsically biased by selection criteria: 12 exclusion criteria are reported in the TORCH trial [], 19 in the UPLIFT [] and 22 in the POET-COPD (Prevention of Exacerbations with Tiotropium in COPD) trial []. Comorbidity, cognitive impairment, depression and physical limitations, which are the hallmark of COPD in the elderly, are among the most recurrent exclusion criteria. For instance, the means of participants in these trials were 65 years (range 40–80; SD 8.2) for TORCH, 65 years (SD 8.0) for UPLIFT, and 63 (SD 9.0) for POET-COPD. As a consequence, trial-based information “may not” apply to the average elderly COPD patient, the one we daily care for in our wards and ambulatories.
- 2)Inhaler devices, seemingly simple to use, may be quite demanding for an elderly COPD patient. Indeed, coordination and respiratory muscle strength are variously required to correctly inhale the drug. It has been proved that cognitive impairment dramatically impacts the ability to correctly use the inhalers: scoring less than 24 on the Mini-Mental State Examination (MMSE) test, a simple screening instrument, is associated with a very high risk of failure []; even an abnormal pentagon copying test, a component of the MMSE assessing constructive ability, identifies patients unable to use inhaler devices (Fig. 4). The adherence to both pharmacological and non-pharmacological therapy is frequently poor in the presence of cognitive impairment. Either a screening test, such as the MMSE, or a confirmatory neuropsychological assessment, like the Mental Deterioration Battery, or a test of secondary memory, e.g. the Rey's fifteen word test, successfully identifies COPD patients at risk of poor compliance [65,66,67].
- 3)Repeated rehabilitation can dramatically slow the decline of health status and decrease the need of health care as well as improve COPD-related mood disorders [68,69]. Based on these evidences, depressed and disabled patients should be considered for and not excluded from rehabilitation programs. These beneficial effects are also evident in older [] and severely diseased patients [], but rehabilitation remains under-prescribed [].
- 4)Many problems characterize this patient and require dedicated care to minimize her/his sufferance (suffering) and to help relatives and caregivers []. Unfortunately, at variance from palliative care for the neoplastic patient, palliative care for the respiratory patient, is poorly available and less perceived as an important health need []. The few available experiences show that providing at home palliative care is quite demanding and poses important organization problems []. For a comprehensive overview of the subject, the reader is referred to the state of art review by Halpin and colleagues [
- 5)Elderly COPD patients are exposed to an important risk of adverse drug reactions due to overdosage of drugs with renal clearance. Indeed, sarcopenia, a common trait of severe COPD, blunts the creatinine rise due to depressed glomerular filtration rate. Thus, moderate (GFR = 60–30) and even severe renal failure may remain unrecognized []. This problem can emerge in the occasion of acute exacerbation requiring antibiotics or chronically for non-respiratory drugs and also for some topic bronchodilators which are fractionally adsorbed and cleared by the kidney.
- 6)Polypathology and inherent polypharmacy is the rule in the elderly COPD patient []. It is frequently unclear to which extent guidelines for individual diseases apply to such a complex patient. For example, beta-blockers for coexisting CHF have historically been considered to worsen bronchial obstruction in COPD, whereas they are currently contraindicated in asthma, but not in COPD []. Furthermore, highly prevalent comorbidities can dramatically impact the respiratory function; for example, osteoporosis can account for vertebral fractures and, then, a restrictive component of the respiratory dysfunction []. Analogously, obstructive sleep apnea syndrome, which is very common but has atypical presentations in the elderly [], can directly affect the respiratory function. The screening, assessment and treatment of comorbidities in COPD patients are therefore a pivotal approach deserving systematic attention by clinicians.
- 7)Hypercatabolism and accelerated loss of muscle mass characterize severe exacerbations of COPD, but they also are a sort of phenotypic trait of an important fraction of COPD patients. Thus, attempts at treating promptly the exacerbation, so that the inflammatory response ceases, and providing nutritional support and rehabilitation are key issues in the treatment of exacerbated COPD. Nutritional interventions could improve both respiratory and peripheral muscle strength, but not respiratory function indexes []. As for very frail and disabled geriatric patients [
Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis.Respirology. 2013; https://doi.org/10.1111/resp.12070], a comprehensive intervention program, mainly based on exercise and nutritional support, seems worth testing.
- Collins P.F.
- Elia M.
- Stratton R.J.
7. How should the physicians approach the elderly COPD patient? Does the real world approach change as a function of specialty?
- •COPD is highly prevalent, but it frequently remains unrecognized in the elderly due to atypical presentation and confounding by comorbidity.
- •A relevant proportion of elderly people cannot perform a satisfactory spirometry, i.e. a spirometry meeting both quality and repeatability criteria. This further makes a gold standard diagnosis of COPD problematic.
- •COPD dramatically impacts health status of elderly patients, but an optimal and multidimensional treatment can significantly limit this effect.
- •Comorbidity has a major prognostic role, but selected comorbidity, e.g. chronic renal failure and coronary artery disease, frequently remains unrecognized.
- •Therapeutic recommendations coming from large scale trials only partly apply to the elderly patient, because they have been obtained on populations which are poorly representative of the real world elderly population.
- •The internists, who care for the majority of elderly COPD patients, should aim at integrating components of approach to COPD by different specialties in order to provide a truly comprehensive and effective treatment.
Conflict of interests
- Chronic obstructive pulmonary disease among adults — United States.MMWR. 2012; 61: 938-943
- The prevalence of chronic obstructive pulmonary disease (COPD) in Germany. Results of the BOLD study.Dtsch Med Wochenschr. 2008; 133: 2609-2614
- The prevalence of COPD: using smoking rates to estimate disease frequency in the general population.Chest. 2000; 117: 354S-359S
- Trends in cause-specific mortality in oxygen-dependent chronic obstructive pulmonary disease.Am J Respir Crit Care Med. 2011; 183: 1032-1036
- Shortened telomeres in circulating leukocytes of patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med. 2009; 179: 566-571
- Telomere dysfunction, autoimmunity and aging.Aging and Disease. 2011; 2: 524-537
- Telomere length in cardiovascular disease: new challenges in measuring this marker of cardiovascular aging.Future Cardiol. 2011; 7: 789-803
- Accelerated telomere shortening in leukocyte subpopulations of patients with coronary heart disease: role of cytomegalovirus seropositivity.Circulation. 2009; 120: 1364-1372
- Copenhagen City Heart Study: longitudinal analysis of ventilatory capacity in diabetic and nondiabetic adults.Eur Respir J. 2002; 20: 1406-1412
- Annual change in pulmonary function and clinical phenotype in chronic obstructive pulmonary disease.Am J Respir Crit Care Med. 2012; 185: 44-52
- Lung volume reference values for women and men 65 to 85 years of age.Am J Respir Crit Care Med. 2009; 180: 1083-1091
- The aging respiratory system — pulmonary structure, function and neural control.Respir Physiol Neurobiol. 2013; 87 ([doi: S1569-9048(13)00091-8]): 199-210
- Chronic obstructive pulmonary disease. An original model of cognitive decline.Am Rev Respir Dis. 1993; 148: 418-424
- Correlation between cognitive impairment and dependence in hypoxemic COPD.J Clin Exp Neuropsychol. 2008; 30: 141-150
- Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease.Ann Intern Med. 1987; 106: 196-204
- Exacerbated chronic obstructive pulmonary disease: a frequently unrecognized condition.J Intern Med. 2002; 252: 48-55
- Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.Eur Respir J. 2004; 23: 932-946
- Quality control of spirometry in the elderly. The SA.R.A. study. SAlute Respiration nell'Anziano = Respiratory Health in the Elderly.Am J Respir Crit Care Med. 2000; 161: 1094-1100
- Prevalence and underdiagnosis of COPD by disease severity and the attributable fraction of smoking. Report from the Obstructive Lung Disease in Northern Sweden Studies.Respir Med. 2006; 100: 264-272
- Standardisation of spirometry.Eur Respir J. 2005; 26: 319-338
- FEV(6) is an acceptable surrogate for FVC in the spirometric diagnosis of airway obstruction and restriction.Am J Respir Crit Care Med. 2000; 162: 917-919
- The FEV1/FEV6 predicts lung function decline in adult smokers.Respir Med. 2002; 96: 444-449
- Spirometric reference values for the 6-s FVC maneuver.Chest. 2003; 124: 1805-1811
- Spirometric reference equations for European females and males aged 65–85 yrs.Eur Respir J. 2004; 24: 397-405
- Validation of FEV6 in the elderly: correlates of performance and repeatability.Thorax. 2008; 63: 60-66
- Spirometric reference values from a sample of the general U.S. population.Am J Respir Crit Care Med. 1999; 159: 179-187
- Diagnosis of airway obstruction in the elderly: contribution of the SARA study.Int J Chron Obstruct Pulmon Dis. 2012; 7: 389-395
- The major limitation to exercise performance in COPD is dynamic hyperinflation.J Appl Physiol. 2008; 105: 753-755
- Effects of tiotropium and formoterol on dynamic hyperinflation and exercise endurance in COPD.Respir Med. 2010; 104: 1288-1296
- Exhaled breath profiling enables discrimination of chronic obstructive pulmonary disease and asthma.Am J Respir Crit Care Med. 2009; 180: 1076-1082
- An investigation on electronic nose diagnosis of lung cancer.Lung Cancer. 2010; 68: 170-176
- Exhaled breath analysis for the monitoring of elderly COPD patients health-state.AIP Conference Proceedings. 2011; 1362: 155-156
- Reproducibility and respiratory function correlates of exhaled breath fingerprint in chronic obstructive pulmonary disease.PLoS One. 2012; 7: e45396https://doi.org/10.1371/journal.pone.0045396
- Exhaled volatile organic compounds as biomarkers for respiratory diseases.Eur Respir Mon. 2010; 49: 130-139
- An electronic nose in the discrimination of patients with asthma and controls.J Allergy Clin Immunol. 2007; 120: 856-862
- Exhaled ethane. An in vivo biomarker of lipid peroxidation in interstitial lung diseases.Chest. 2005; 128: 2387-2392
- Prospects for clinical application of electronic-nose technology to early detection of Mycobacterium tuberculosis in culture and sputum.J Clin Microbiol. 2006; 44: 2039-2045
- Bacteria classification using Cyranose 320 electronic nose.Biomed Eng Online. 2002; 1: 4
- Electronic nose analysis of bronchoalveolar lavage fluid.Eur J Clin Invest. 2011; 41: 52-58
- Aging and disability affect misdiagnosis of COPD in elderly asthmatics: the SARA study.Chest. 2003; 123: 1066-1072
- Identification of asthma phenotypes using cluster analysis in the Severe Asthma Research Program.Am J Respir Crit Care Med. 2010; 181: 315-323
- Do GOLD stages of COPD severity really correspond to differences in health status?.Eur Respir J. 2003; 22: 444-449
- The health impact of undiagnosed airflow obstruction in a national sample of United States adults.Am J Respir Crit Care Med. 2001; 164: 372-377
- Multidimensional assessment and treatment of the elderly with COPD.in: European respiratory society monograph. Respiratory diseases in the elderly. 43. 2009: 35-55https://doi.org/10.1183/1025448x.00043004
- Gruppo Italiano di Farmacovigilanza (Italian Group for Pharmacological Survey in the Elderly). Predicting length of stay of older patients with exacerbated chronic obstructive pulmonary disease.Aging (Milano). 2001; 13: 49-57
- Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life.Arch Intern Med. 2007; 167: 60-67
- Dynamic hyperinflation and exercise intolerance in chronic obstructive pulmonary disease.Am J Respir Crit Care Med. 2001; 164: 770-777
- Impact of exacerbations on COPD.Eur Respir Rev. 2010; 19: 113-118https://doi.org/10.1183/09059180.00002610
- Socioeconomic status and hospitalization in the very old: a retrospective study.BMC Public Health. 2007; 7: 227
- Construct validity of activities of daily living scale: a clue to distinguish the disabling effects of COPD and congestive heart failure.Chest. 2005; 127: 830-838
- Prognosis in chronic obstructive pulmonary disease.Am Rev Respir Dis. 1986; 133: 14-20
- Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease.N Engl J Med. 2007; 356: 775-789
- A 4-year trial of tiotropium in chronic obstructive pulmonary disease.N Engl J Med. 2008; 359: 1543-1554
- From the global strategy for the diagnosis, management and prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD).(Available from:)
- The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease.N Engl J Med. 2004; 350: 1005-1012
- Alternative ways of expressing FEV1 and mortality in an elderly population with and without COPD.Eur Respir J. 2013; 41: 800-805
- The progression of chronic obstructive pulmonary disease is heterogeneous: the experience of the BODE cohort.Am J Respir Crit Care Med. 2011; 184: 1015-1021
- Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease.Eur Respir J. 1997; 10: 2794-2800
- Electrocardiographic signs of chronic cor pulmonale: a negative prognostic finding in chronic obstructive pulmonary disease.Circulation. 1999; 99: 1600-1605
- Drawing impairment predicts mortality in severe COPD.Chest. 2006; 130: 1687-1694
- Double jeopardy.Chest. 2006; 130: 1636-1638
- Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease.Am J Med. 1995; 98: 272-277
- Tiotropium versus salmeterol for the prevention of exacerbations of COPD.N Engl J Med. 2011; 364: 1093-1103
- A simple drawing test to identify patients who are unlikely to be able to learn to use an inhaler.Int J Clin Pract. 2006; 60: 510-513
- Verbal memory impairment in COPD: its mechanisms and clinical relevance.Chest. 1997; 112: 1506-1513
- The Mental Deterioration Battery: normative data, diagnostic reliability and qualitative analyses of cognitive impairment.Eur Neurol. 1996; 36: 378-384
- Examen clinique en psychologie.Presses Universitaires de France, Paris1964
- Outcomes of depressed patients undergoing inpatient pulmonary rehabilitation.Am J Geriatr Psychiatry. 2006; 14: 466-475
- Seven-year time course of lung function, symptoms, health-related quality of life, and exercise tolerance in COPD patients undergoing pulmonary rehabilitation programs.Respir Med. 2007; 101: 1961-1970
- Can individualized rehabilitation improve functional independence in elderly patients with COPD?.Chest. 2005; 128: 1194-1200
- Efficacy of pulmonary rehabilitation in chronic respiratory failure (CRF) due to chronic obstructive pulmonary disease (COPD): the Maugeri study.Respir Med. 2007; 101: 2447-2453
- Age does not hamper the response to pulmonary rehabilitation of COPD patients.Age Ageing. 2008; 37: 530-535
- Clinical and prognostic implications of cognitive dysfunction and depression in COPD.Current Respiratory Medicine Reviews. 2007; 3: 107-115
- Palliative care provision for patients with chronic obstructive pulmonary disease.Health Qual Life Outcomes. 2007; 5: 17
- Implementing a palliative care trial in advanced COPD: a feasibility assessment (the COPD IMPACT study).J Palliat Med. 2013; 16: 67-73
- Palliative and end-of-life care for patients with respiratory disease.in: European respiratory society monograph. Respiratory diseases in the elderly. 43. 2009: 327-353https://doi.org/10.1183/1025448x.00043021
- Chronic renal failure: a neglected comorbidity of COPD.Chest. 2010; 137: 831-837
- The MRC dyspnoea scale by telephone interview to monitor health status in elderly COPD patients.Respir Med. 2010; 104: 1027-1034
- Use of beta-blockers in patients with COPD.Ann Pharmacother. 2004; 38: 142-145
- Reduced pulmonary function in patients with spinal osteoporotic fractures.Osteoporos Int. 1998; 8: 261-267
- Clinical characteristics of obstructive sleep apnea in community-dwelling older adults.J Am Geriatr Soc. 2006; 54: 1740-1744
- Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis.Respirology. 2013; https://doi.org/10.1111/resp.12070
- Exercise training and nutritional supplementation for physical frailty in very elderly people.N Engl J Med. 1994; 330: 1769-1775
- Physician specialty as a source of heterogeneity in the care of patients with COPD.Chest. 2011; 140: 1666-1667
- Comorbidities in current COPD guidelines.Eur Respir Mon. 2013; 59: 217-222
- Costs of chronic bronchitis and COPD: a 1-year follow-up study.Chest. 2003; 123: 784-791
☆Grant support: none.