Treatment of chronic obstructive pulmonary disease in older patients: a practical guide

Navigating COPD in Aging Populations: Insights Into Pathophysiology and Comprehensive Care

Chronic obstructive pulmonary disease (COPD) poses a significant and growing health burden among aging populations, marked by increasing prevalence and complex management challenges specific to elderly patients. This review explores the multifaceted interplay between COPD and aging, highlighting overlapping pathophysiological processes and comorbidities that complicate diagnosis and treatment. We examine age-specific management strategies, emphasizing the need for tailored approaches that account for the unique physical, cognitive, and health-related quality of life impacts on older adults. Additionally, we discuss preventive treatments and the critical roles of mental health, end-of-life care, and caregiver support in comprehensive disease management. The importance of integrative approaches to enhancing health care delivery is also underscored. Finally, we outline future directions, focusing on novel treatment pathways and the identification of biomarkers for early detection. Addressing these elements is essential for optimizing care in this vulnerable population and alleviating the significant societal and economic impacts of COPD among aging patients.

[Chronic obstructive pulmonary disease in the elderly]

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent diseases. Its prevalence increases with the age, and causes a high morbidity and mortality in the elderly population. COPD is currently considered as an inflammatory disease characterised by a pulmonary obstruction that is not fully reversible, and is associated with a high comorbidity. The treatment in the elderly does not differ much from that used in young adults, although the high comorbidity, the multiple prescription drugs and the use of different inhalation devices means that treatment has to be adapted to each patient. The presence of exacerbations, inactivity, systemic inflammation and dyspnea leads to a decrease in activity and loss of physical function. In this review we will update the physiology, diagnosis and treatment of COPD in the elderly, and the prevention of geriatric syndromes in this disease.

Burden of chronic obstructive pulmonary disease in Medicare beneficiaries residing in long-term care facilities

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD increases health care resource utilization and spending and adversely affects quality of life. Data from the clinical and economic outcomes in Medicare beneficiaries with COPD who reside in long-term care (LTC) facilities are limited.

OBJECTIVE

The purpose of this study was to investigate the clinical and economic outcomes associated with COPD in Medicare beneficiaries residing in LTC facilities.

METHODS

This retrospective cohort study analyzed data from MarketScan Medicaid, a large US administrative claims database containing data on Medicaid programs in 8 states. The study cohort comprised LTC facility residents aged > or =60 years who had a diagnosis of COPD. Eligible patients also had a prescription filled between January 1, 2003, and June 30, 2005, for one of the following COPD treatments: fluticasone propionate + salmeterol xinafoate, tiotropium bromide, ipratropium bromide, or ipratropium bromide + albuterol sulfate. The date of the first prescription fill was considered the index date. Measures of health care resource utilization included COPD-related and all-cause hospitalizations and emergency department (ED) visits. Cost analysis outcomes included COPD-related and all-cause inpatient, outpatient, pharmacy, LTC, and total costs during the 12-month postindex period.

RESULTS

Data from 3037 patients were included (63.0% women; 82.2% white; mean [SD] age, 78.1 [10.0] years). A total of 43.3% of patients had > or =1 hospitalization; 90.0%, > or =1 ED visit. With the exception of age <70 years, age was associated with all-cause hospitalization (age 70-<75 years, hazard ratio [HR] = 1.31 [95% CI, 1.03-1.68]; age 75-<80 years, HR = 1.40 [95% CI, 1.11-1.78]; age > or =80 years, HR = 1.48 [95% CI, 1.19-1.85]). Age was not associated with COPD-related hospitalization, all-cause ED visits, or COPD-related ED visits. The risk for all-cause hospitalization in white patients was significantly lower compared with that in nonwhite patients (HR = 0.79 [95% CI, 0.69-0.91]). Patients with comorbid asthma had a higher risk for a COPD-related ED visit (HR = 1.34 [95% CI, 1.08-1.66]) than did patients without asthma. Preindex all-cause hospitalization was associated with COPD-related hospitalization (HR = 1.78 [95% CI, 1.49-2.14]) and all-cause hospitalization (HR = 2.05 [95% CI, 1.932.19]). Twelve-month COPD-related and all-cause direct expenditures per beneficiary were US $7391 and $48,183. In COPD-related and all-cause estimates, mean (SD) LTC costs were the largest cost components ($5629 [$12,562] and $32,966 [$14,871], respectively), followed by pharmacy costs ($956 [$957] and $5565 [$3873]), inpatient costs ($466 [$3393] and $6436 [$22,603]), and outpatient costs ($341 [$1793] and $3216 [$6458]).

CONCLUSION

This study found that the utilization of health care resources and economic burden of LTC residents with COPD were primarily due to LTC, pharmacy, and inpatient costs.

Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions

Part I of this two-part introduction to this Special Issue on the practice of physical therapy in the 21st century outlines the epidemiological basis and rationale for evidence-informed physical therapy practice for addressing contemporary health priorities. This evidence emanates from the definition of health by the World Health Organization (WHO) and the International Classification of Functioning (ICF), and WHO and other international databases on the prevalence of lifestyle conditions. Lifestyle conditions include ischemic heart disease, smoking-related conditions, hypertension and stroke, obesity, diabetes, and cancer. Epidemiological data combined with evidence supporting the effectiveness of noninvasive interventions related to physical therapy to address these priorities (e.g., health education and exercise) are highly consistent with the promotion of health and wellness and the ICF. Given their commitment to exploiting effective noninvasive interventions, physical therapists are in a preeminent position to focus on prevention of these disabling and lethal conditions in every client or patient, their cure in some cases, as well as their management. Thus, a compelling argument can be made that clinical competencies in 21st century physical therapy need to include assessment of smoking and smoking cessation (or at least its initiation), basic nutritional assessment and counseling, recommendations for physical activity and exercise, stress assessment and basic stress reduction recommendations, and sleep assessment and basic sleep hygiene recommendations. The physical therapist can then make an informed clinical judgment regarding whether a client or patient needs to be referred to another professional related to one or more of these specialty areas. The prominence of physical therapy as an established health care profession and its unique pattern of practice (prolonged visits over prolonged periods of time) attest further to the fact that physical therapists are uniquely qualified to lead in the assault on lifestyle conditions. Evidence-based physical therapy practiced within the context of epidemiological indicators (i.e., evidence-informed practice) maximally empowers clinicians to promote lifelong health in every person and in turn, the health of communities. This vision of physical therapy's leading role in health promotion and health care in the 21st century holds the promise of reducing the need for invasive health interventions (drugs and surgery). Part II of this introduction describes evidence-based physical therapy practice within this context of evidence-informed practice.

Hospital and emergency department utilization associated with treatment for chronic obstructive pulmonary disease in a managed-care Medicare population

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition with high morbidity and mortality among older and disabled adults. Few studies have examined the comparative effectiveness of maintenance therapies for chronic obstructive pulmonary disease (COPD) in this vulnerable population.

OBJECTIVES

The study aims to compare healthcare resource utilization associated with hospitalization or emergency department (ED) visits between FDA-approved inhaled corticosteroid/long-acting beta-agonist combinations [fluticasone propionate 250 microg/salmeterol 50 microg combination (FSC)] and anticholinergic treatments (ATC) in managed-care Medicare beneficiaries with COPD.

RESEARCH DESIGN AND METHODS

Data from the Integrated Health Care Information Systems (IHCIS) National Managed Care Benchmark Database was used in this retrospective, observational cohort study. The cohort consisted of managed-care Medicare beneficiaries with a diagnosis of COPD [International Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM) codes 491.xx, 492.xx, or 496.xx] without evidence of comorbid asthma (ICD-9-CM 493.xx) who received treatment with FSC or ATC between 2003 and 2005. Cox proportional hazards regression models were conducted to examine the risk of all-cause and COPD-related hospitalizations and emergency department (ED) visits.

RESULTS

COPD patients treated with FSC had a 18% lower risk of a COPD-related hospitalization (HR = 0.82; 95% CI = 0.75, 0.89) and an ED visit (HR = 0.82; 95% CI = 0.76, 0.89) compared to patients treated with ATC. Findings were similar for all-cause utilization (hospitalization HR = 0.83; 95% CI = 0.78, 0.88; ED visit HR = 0.84; 95% CI = 0.80, 0.88).

CONCLUSIONS

FSC is associated with a lower risk of COPD-related exacerbation events relative to ATC in managed-care Medicare beneficiaries with COPD. Findings from this study are only generalizable to managed-care Medicare beneficiaries residing in the community.

Long-term safety of nebulized formoterol: Results of a twelve-month open-label clinical trial

Formoterol fumarate is a long-acting β2-agonist that is an effective bronchodilator for the maintenance management of patients with chronic obstructive pulmonary disease. The safety profile of the newly developed nebulized formoterol was evaluated over a twelve-month period in an open-label, active-control study. After completing a twelve-week double-blind double-dummy period, 569 subjects with chronic obstructive pulmonary disease entered an open-label extension study and received twice-daily 20 µg formoterol fumarate inhalation solution for nebulization (FFIS) or 12 µg formoterol fumarate dry powder inhalation (FA) for 52 weeks. Most of the FFIS-treated subjects (86%) completed at least six months of open-label treatment with over 90% compliance, comparable to the FA group (88%). Results of safety monitoring for adverse events, laboratory values, and cardiac changes were similar between treatment groups. Three hundred forty (73%) of FFIS-treated subjects and 83 (78%) of FA-treated subjects experienced an adverse event over the course of the study, the majority of which were mild to moderate and considered unrelated to treatment. COPD exacerbation occurred in 15.8% of FFIS-treated and 17.9% of FA-treated subjects. Deaths, serious adverse events, and discontinuations for adverse events occurred in 1.3, 16.2, and 5.4% of the nebulized group versus 1.9, 17.9, and 7.5% of the inhaled group, respectively. There were no clinically important changes from baseline in laboratory tests, including serum potassium and glucose, or vital signs and no treatment-related increases in cardiac arrhythmias, heart rate, or QTc prolongation. We conclude that nebulized formoterol fumarate twice daily is well tolerated over long-term treatment in moderate-to-severe COPD subjects and has a similar safety profile to the DPI formulation.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Effect of Oral Aminophylline on Pulmonary Function Improvement and Tolerability in Different Age Groups of COPD Patients

BACKGROUND

Aminophylline therapy in elderly patients with COPD is rarely studied. This study attempted to explore the symptoms, pulmonary function improvement, and adverse events related to aminophylline therapy in COPD patients of different age groups.

METHODS AND RESULTS

We designed a 10-week prospective study. Two groups of COPD patients were classified based on age (30 patients in group 1, 55 to 74 years old; 30 patients in group 2, 75 to 90 years old), with matched disease severity. After stopping all methylxanthines for 2 weeks in the washout period, therapy began with long-acting 225-mg aminophylline compounds bid po for 8 weeks. Pulmonary functions, respiratory symptoms, and laboratory examinations were checked at the initial visit and at every 4-week visit. After aminophylline therapy, the drug serum level showed no significant difference in either group (9.73 +/- 6.35 mg/dL [+/- SD] in group 1 and 7.82 +/- 6.68 mg/dL in group 2, p = 0.359). Improvements of FEV1 and FVC were noted in both groups; however, there was no significant difference. Peak expiratory flow rate (PEFR) was significantly improved in group 1 but not in group 2 (group 1, from 3.51 to 3.97 L/s, p < 0.05; group 2, from 2.78 to 3.08 L/s, p > 0.05). The degree of improvement in symptom scores was not different between the groups, except there was significantly less chest tightness in group 2 (from 0.79 +/- 0.74 to 0.40 +/- 0.50, p < 0.05). Electrolyte imbalance and arrhythmia did not appear in either group.

CONCLUSIONS

Our study demonstrated that the safety and drug concentration of aminophylline at a standard dose are not different in the sixth to ninth decades of COPD patients. Younger patients have more improvement in PEFR than older patients; however, older COPD patients have more symptoms relief in chest tightness after aminophylline therapy.

Chronic Obstructive Pulmonary Disease in Women

Chronic obstructive pulmonary disease is a chronic, progressive, debilitating disease caused primarily by smoking. This article will present a case study of a female with chronic obstructive pulmonary disease with emphasis on the physical examination, laboratory data, and healthcare management.

Health-related QOL in acute exacerbations of chronic bronchitis and chronic obstructive pulmonary disease: a review of the literature

There is a lack of emphasis on health-related QOL (HR-QOL) changes associated with acute exacerbation of chronic bronchitis (CB) or chronic obstructive pulmonary disease (COPD). The aim of this review is to examine the use of HR-QOL instruments to evaluate acute exacerbation of CB or COPD, so as to form recommendations for future research.A literature search of papers published between 1966 and July 2003 identified more than 300 articles that used acute exacerbation of CB or COPD as the search term. However, only 21 of these studies employed HR-QOL measures as predictors of outcome or in the assessment of the impact, evolution or treatment of acute exacerbations of COPD or CB. A variety of HR-QOL measures were used, both generic and disease specific. The disease-specific St George's Respiratory Questionnaire (SGRQ), devised for patients with stable CB and with a recall period of 1-12 months, was the most widely used measure, with the Chronic Respiratory disease Questionnaire (CRQ) and the Baseline and Transitional Dyspnoea Index (BDI, TDI) being the only other disease-specific measures used. Most measures, both generic and disease specific, performed adequately when used during acute exacerbation of CB or COPD and indicated poor HR-QOL during acute exacerbation, which improved on resolution of the exacerbation. Relationships were evident between HR-QOL during an acute exacerbation and various outcomes, including post-exacerbation functional status, hospital re- admission for acute exacerbation or COPD, and mortality. There is a need for studies of treatments for acute exacerbation of CB or COPD to include an appropriate HR-QOL instrument to aid in the stratification of patients so as to target the right treatment to the right patient group. While a new instrument could be developed to measure HR-QOL during acute exacerbation of CB or COPD, currently available disease-specific measures such as the CRQ and the SGRQ appear to be acceptable to patients during acute exacerbation. However, the recall period of the SGRQ symptoms component should be shortened to make it more appropriate for use during acute exacerbation.