RESPIRATORY DISEASES AND DISORDERS Suggestions for Lecturer -1-hour lecture -Use GNRS slides alone or to supplement own teaching materials. -Refer to GNRS for further content, including strength of evidence (SOE) levels. -Supplement lecture with handouts. -The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

OBJECTIVES Know and understand: How to evaluate common respiratory symptoms: dyspnea, chronic cough, and wheezing The 5 A’s of helping patients to quit smoking How to recognize and treat the major pulmonary diseases and disorders in older patients Topic

Age-related Pulmonary Changes TOPICS COVERED Age-related Pulmonary Changes Common Respiratory Complaints and Symptoms Major Pulmonary Diseases in Older People Topic

AGE-RELATED PULMONARY CHANGES Reduced airway size Shallow alveolar sacs Reduced chest wall compliance Intercostal muscle atrophy Reduction in diaphragmatic strength by 25% With advancing age, the size of the airways is reduced and the alveolar sacs become shallow because of alterations in connective tissue. Chest wall compliance is reduced as a consequence of kyphoscoliosis, calcification of the costal cartilage, and arthritic changes in the costovertebral joints. Intercostal muscle atrophy and reduction in diaphragmatic strength result from sarcopenia. These processes result in a decline of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) of 25 to 30 mL per year in nonsmokers and approximately double that (60 to 70 mL per year) in smokers aged 65 years and over. The normal A-a gradient increases with age and can be approximated by the following formula: (Age / 4) + 4. The PaO2 decreases with age and can be approximated by the following equation: PaO2 = 110 − (0.4 × age). Studies of age-specific alterations in pulmonary function are limited by common and important comorbidities experienced by older people, including smoking-related diseases, occupational and industrial exposures, and other significant organ dysfunction such as heart failure or deconditioning. These limitations notwithstanding, decrements in various aspects of pulmonary function occur with aging. Topic

DIFFICULTIES IN RECOGNIZING RESPIRATORY SYMPTOMS A common misperception is that older people tend to overestimate or exaggerate respiratory symptoms —the opposite is more often true Older people often have more than one cause of their problems Dyspnea, cough, and wheezing may overlap The causes may include a combination of diseases such as asthma or emphysema, obstructive sleep apnea, heart failure, and GERD GERD = gastroesophageal reflux disease As an example of the difficulty of recognizing respiratory symptoms, many older people and their providers tend to underestimate the importance of dyspnea. It may go undiagnosed until advanced disease is evident. This is partly due to the fact that dyspnea is blamed on deconditioning and age. Older people often adjust their activity level to compensate for insidiously shrinking lung function and disabling dyspnea. Such changes in life style often go unnoticed by family, the patient’s provider, and even the patient. Pulmonary or cardiac disorders, or both, may underlie such modifications in life style, and testing (eg, pulmonary function tests or chest radiography) may reveal major abnormalities such as asthma, emphysema, or pulmonary fibrosis. Topic

RHINOSINUSITIS Approaches to diagnosis, treatment do not differ with age Treat bacterial rhinosinusitis with analgesics, saline irrigation, and antibiotics if symptoms >7 days or worsen But early antibiotics in mild disease can be harmful Treat chronic rhinosinusitis with topical nasal steroids and saline irrigation Treat allergic rhinosinusitis by recommending avoidance of inciting allergens and/or with topical nasal steroids and anti-allergy medications The use of chronic topical nasal steroids can possibly increase the risk of epistaxis. Anti-allergy medications: Be aware of anticholinergic effects, particularly in the older population. Topic

DYSPNEA Common causes: COPD, cardiac disease, asthma, interstitial lung disease, deconditioning Does not necessarily correlate with oxygenation or pulmonary function tests but significantly predicts QOL Thorough H & P can help tailor testing and empirical treatment choices Patient’s description can be revealing “Heavy” may imply cardiac dysfunction or deconditioning “Tight” may imply angina or asthma COPD = chronic obstructive pulmonary disease In an older person presenting with dyspnea and associated nocturnal cough, one would first consider common diseases such as asthma, emphysema, allergic rhinitis with postnasal drip, and GERD. A reasonable approach would be minimal testing (eg, pulmonary function tests only) followed by an empiric trial directed toward the most likely cause. In the same patient, the presence of significant weight loss or constitutional symptoms (fever, night sweats) could suggest other diseases, such as malignancy or tuberculosis. Topic

CHRONIC COUGH Usually has a benign cause The most common causes are postnasal drip, asthma, and GERD A reasonable approach is empiric treatment for these conditions A combination of these conditions may contribute, so treatment for multiple causes may be warranted when single therapies are ineffective Postnasal drip, asthma, and GERD together account for over 90% of causes of chronic cough identified in most series. Less common yet important differential diagnostic considerations of cough in older people include drug effects (eg, angiotensin-converting enzyme inhibitors), heart failure, laryngeal dysfunction, Bordetella pertussis infection, chronic cough after viral upper respiratory tract infection or secondary bacterial infections, recurrent aspiration, and respiratory tract abnormalities such as bronchiectasis or airway tumors. Topic

WHEEZING Common causes include: Asthma COPD Postnasal drip Pulmonary edema associated with heart failure may present as “cardiac asthma” Airway hyperresponsiveness from chronic bronchitis is not uncommon in older patients with a history of wheezing, sputum, and tobacco use Although asthma is a common cause of wheezing in all age groups, it is not the most common cause, particularly if the wheezing is not associated with cough or dyspnea. Topic

MAJOR PULMONARY DISEASES IN OLDER PEOPLE Asthma COPD Obstructive sleep apnea Idiopathic pulmonary fibrosis Pulmonary thromboembolism Pneumonia Lung cancer Pneumonia and lung cancer are covered in other GNRS slide sets: Infectious Diseases and Oncology, respectively. Topic

ASTHMA EPIDEMIOLOGY 5%–10% of people  65 years, particularly nonsmokers, meet the criteria for obstruction and bronchial hyperreactivity Methacholine challenge is safe, effective way to identify asthma in older adults Asthma is under-recognized, undertreated in older adults After childhood, there is a second peak in the prevalence of asthma beyond the age of 65; 5% to 10% of older people meet criteria for obstruction and bronchial hyperreactivity. The rate of death from asthma has increased most significantly in those aged 65 and over, accounting for up to 50% of all asthma deaths. This is likely due to reduced awareness of bronchial constriction on the part of the patient (with delays in seeking medical attention), as well as under-recognition and undertreatment on the part of clinicians. >50% of all asthma deaths are in people ≥65 Topic

ASTHMA TREATMENT ICS or other controller drugs, such as LTRAs, are the mainstay of therapy Prescribe the lowest effective dose Use β-agonists as needed as reliever medication Instruct in the proper use of PEF monitoring (because of the older person’s decreased perception of bronchoconstriction) Consider an asthma action plan ICS = inhaled corticosteroids; LTRA = leukotriene receptor antagonist; PEF = peak expiratory flow. The clinician should instruct the patient in correct activation of the inhaler device and observe the patient actually using it. Neurologic, muscular, and arthritic diseases can lead to suboptimal timing and discoordination in the actuation of the inhaler. Counsel the patient about rinsing the oropharynx to avoid thrush. In older people, theophylline is fraught with adverse effects and drug interactions and should be considered a third-line drug to be used only as a once-daily medication in the evening for severe asthma or COPD, targeting a serum level of 10 to 12 mg/dL if tolerated. Oral corticosteroids are discussed in the next section on COPD. Although the response to relievers such as β-agonists declines with age, these drugs remain a mainstay as an as-needed reliever medication. The potential for adverse effects of β-agonists—for example, hypokalemia or possible QT-interval prolongation in cardiac patients on digoxin or other medications—warrants adequate controller use by asthmatic patients to minimize their overreliance on the β-agonist. The use of long-acting β-agonists is helpful for long-term maintenance therapy and nocturnal symptoms. Topic

COMMONLY USED INHALED MEDICATIONS (1 of 2) Class of drug Generic name Trade name β-Agonists Albuterol Proventil Ventolin Formoterol* Foradil Pirbuterol Maxair Salmeterol Serevent Corticosteroids Beclomethasone Beclovent Vanceril QVAR Budesonide Pulmicort Flunisolide AeroBid Fluticasone Flovent Triamcinolone Azmacort * Powder for oral inhalation Topic

COMMONLY USED INHALED MEDICATIONS (2 of 2) Class of drug Generic name Trade name Combination β-agonist and corticosteroid Fluticasone propionate and salmeterol Advair Budesonide and formoterol Symbicort Mometasone and formoterol Dulera Others Cromolyn Intal Ipratropium Atrovent Tiotropium* Spiriva Nedocromil Tilade Albuterol-ipratropium Combivent * Powder for oral inhalation Topic

COPD EPIDEMIOLOGY Affects ~15 million people in the US 4th most common cause of death after heart disease, cancer, and stroke Prevalence and mortality rate are increasing, especially in older people Morbidity and mortality from COPD accounts for more than $15 billion per year in US medical care expenditures, mainly due to hospitalization Episodes of acute respiratory failure that require mechanical ventilation are associated with mortality rates ranging from 11% to 46%. Topic

COPD DIAGNOSIS Wheezing = best predictor of airflow limitation Patients with obstructive airflow limitation are 36 times more likely to have wheezing than are patients without this problem Other predictors: Barrel-shaped chest Hyperresonance on percussion Forced expiratory time > 9 seconds measured during the clinical examination The diagnosis of airflow limitation is challenging in that no single item or combination of items from the history and clinical examination excludes airflow limitation. Topic

GOLD GUIDELINES FOR COPD Key Factors for Considering a Diagnosis of COPD Dyspnea Progressive or worsens over time; worse with exercise; persistent (present daily); described as “increased effort to breathe,” “heaviness,” “air hunger,” “gasping” Chronic cough May be intermittent and nonproductive Sputum production Any pattern of chronic sputum production can indicate COPD Risk factors Tobacco smoke; occupational dusts and chemicals; smoke from home cooking and heating fuel; family history, genetic variant (α1-antitrypsin deficiency) Spirometric Classification of COPD FEV1/FVC <70% applies to each category Mild FEV1 ≥ 80% predicted Moderate 50% ≤ FEV1 <80% predicted Severe 30% ≤ FEV1 <50% predicted Very severe FEV1 <30% predicted or FEV1 <50% predicted and chronic respiratory failure GOLD = Global Initiative for Chronic Obstructive Lung Disease; FEV1 = forced expiratory volume in 1 sec; FVC = forced vital capacity. Using the criterion FEV1/FVC <70% may overdiagnose COPD in older, nonsmoking adults. Some experts recommend using FEV1/FVC <65% after age 70, because the changes seen may be related to structural changes that occur in the airways with increasing age. Topic

SMOKING CESSATION SLOWS DECLINE IN LUNG FUNCTION AT ANY AGE The “Five As” (Agency for Health Care Policy and Research): Ask patients about use of tobacco at every office visit Assess readiness to quit Advise patients to quit Assist patients in the quit attempt with aids such as a local cessation program and pharmacologic agents such as bupropion or nicotine replacement Arrange a quit date and a follow-up visit, or contact patient to discuss the quit attempt Aggressive smoking cessation efforts are appropriate even in the oldest- old patient. Topic

DAILY DRUG THERAPY IN COPD β-agonist, ipratropium or tiotropium, or both in combination For more severe disease, an inhaled corticosteroid or long-acting β-agonist, such as salmeterol, plus combined albuterol and ipratropium metered-dose inhaler Can improve adherence and long-term control by reducing the number of inhalers See GNRS4 Table 47.3, “Inhaled Bronchodilators for COPD”, and Table 47.4, “COPD Therapy”. A landmark investigation documented that the use of systemic corticosteroids (intravenous followed by oral) reduces the duration and recurrence of acute exacerbations of COPD for up to 6 months. Importantly, there is no benefit to a course of steroids longer than 14 days. For the few patients (5% to 10%) who do benefit or who require prolonged use of corticosteroids, the risks should be considered, discussed, and documented in the patient’s chart. These risks include peptic ulcer disease, hypertension, cataracts, diabetes mellitus, osteoporosis, psychosis, seizures, poor wound healing, infections, and aseptic necrosis of the hip. Appropriate preventive measures should also be taken in these circumstances of prolonged use, such as using the lowest possible dose of corticosteroids and using supplemental vitamin D, calcium, and perhaps a bisphosphonate for those at risk for osteoporosis. Inhaled corticosteroids are associated with improvement in lung function, airway reactivity frequency of exacerbations, and respiratory symptoms but no impact on rate of decline in lung function. Combination therapy with ICS and a long-acting β-agonist is associated with improved lung function and symptom control but not survival benefit. Topic

OTHER INTERVENTIONS FOR COPD Oxygen therapy Exercise training Respiratory therapy and education Treatment for major depression and anxiety Present in 40% of COPD patients Anxiety may lead patients to seek help in ER or be admitted to the hospital Long-term oxygen therapy benefits patients who have a resting PaO2 of ≤55 mmHg on room air. Use of oxygen for at least 15 hours per day improves survival, exercise tolerance, sleep, and cognitive function. Topic

OBSTRUCTIVE SLEEP APNEA Warrants high index of suspicion Life-threatening, yet potentially correctable Associated with: Stroke Myocardial infarction 3 increase in mortality Often undiagnosed and therefore untreated Sleep-related breathing disorders are very common in older people, and obstructive sleep apnea is the most common type of sleep-related breathing disorder. Topic

TREATMENT OPTIONS FOR SLEEP APNEA Weight loss Avoidance of alcohol and sedatives Sleeping on one’s side or upright Correction of metabolic disorders such as hypothyroidism Continuous positive airway pressure (CPAP) via a nasal mask To increase adherence with the use of CPAP, one might order the treatment with “nasal pillows” to increase comfort and a “ramping technique” to give a delayed rise in the applied pressure after the patient has fallen asleep. Treatment issues are generally the same for the young and the old. Topic

IDIOPATHIC PULMONARY FIBROSIS Relentlessly progressive: median survival 3–5 years Normal presentation: insidious dyspnea and cough Clubbing is often a prominent finding in pulmonary fibrosis and not in emphysema Commonly treated initially with OCS, but only 10%– 20% of patients respond and adverse effects are often prominent Early referral to a subspecialist is warranted if the patient wishes to consider further therapy OCS = oral corticosteroids There are more than 100 causes of restrictive lung diseases; however, the history, examination, serologic testing, and biopsy often leave the patient with the diagnosis of idiopathic pulmonary fibrosis. This disease is increasing in prevalence with the aging of our population. Rarely is it an inherited disorder. Topic

PULMONARY THROMBOEMBOLISM Incidence triples from age 65 to age 90 Age > 70 is a risk factor for missed diagnosis Blood gas is normal in 10%–20% of patients Diagnostic work-up is same as in younger patients 10% recurrence rate within 1 year “Normal blood gas” refers to normal PaO2 and normal A-a gradient for age. Age-specific risk factors for pulmonary thromboembolism include hypercoagulability due to increases in fibrinogen, activated protein-C resistance due to factor-V Leiden gene mutation, malignancy, stasis (decreased mobility due to stroke, heart failure, or arthritis), or vessel injury due to trauma or varicosities. Topic

PULMONARY THROMBOEMBOLISM: PRINCIPLES OF ANTICOAGULATION Same for older and younger adults In older patients it may be even more important to achieve therapeutic levels of heparinization quickly Use of outpatient LMWH while beginning warfarin is supported by well-designed trials There should be an overlap of ~1 to 3 days between heparinization and adequate warfarin therapy with INR target of 2 to 3 In most cases, anticoagulant therapy should continue for at least 6 months LMWH = low-molecular-weight heparin; INR = international normalized ratio. Because of the lessened cardiopulmonary reserve in older patients, it may be even more important to achieve therapeutic levels of heparinization quickly to avoid major adverse hemodynamic or oxygenation defects. Warfarin interacts with many drugs that are commonly used in the older age group. Studies have inconsistently shown that age itself is a risk factor for bleeding due to warfarin. Duration of therapy for at least 6 months has been shown to be superior to 3 months, and the shorter duration should be used only for patients with either a specific risk factor that has been removed or for those in whom the risk of prolonged anticoagulant therapy clearly outweighs that of completing 6 months of therapy. Indeed, patients with multiple ongoing risk factors for pulmonary thromboembolic disease are to be considered for anticoagulation therapy for up to 2 years or longer. Recurrent pulmonary thromboembolism is usually treated with lifelong anticoagulation. Topic

SUMMARY (1 of 2) With age, there is a decline in forced vital capacity, FEV1, and PaO2, while the A-a gradient increases 5%–10% of people ≥65 years meet criteria for asthma Smoking cessation may slow the decline in lung function at any age Inhaled corticosteroids can decrease exacerbations of COPD and improve health status Topic

SUMMARY (2 of 2) The combination of an inhaled corticosteroid with a long-acting bronchodilator can reduce COPD exacerbations, improve lung function and health status, and slow decline in lung function Older people with lung injury recover pulmonary physiology at the same rate as younger cohorts, but in some disease states they may require a longer time to be liberated from the ventilator Topic

CASE 1 (1 of 4) A 72-year-old man comes to the office because he has worsening shortness of breath. He has had dyspnea for the past several years; he now has difficulty walking 2 blocks, and he has had to limit his activity significantly. He notes occasional wheezing. He rarely coughs and has no chest pain, leg edema, orthopnea, dysphagia, fever, or chills. History includes hypertension, depression, and lower back pain. He has a 40 pack-year history of smoking and currently smokes about one half pack of cigarettes each day. Topic

CASE 1 (2 of 4) On physical examination, he has lost 1.4 kg (3 lb). Breath sounds are distant, and there are faint expiratory wheezes bilaterally. Pulmonary function tests show an FEV1/FVC ratio of 55%. FEV1 is at 60% of predicted value and does not improve significantly after challenge with a β-agonist bronchodilator. Topic

Coronary artery disease Lung cancer Vocal cord paralysis CASE 1 (3 of 4) Which of the following is the most likely cause of the patient’s dyspnea? Asthma COPD Coronary artery disease Lung cancer Vocal cord paralysis Topic

Coronary artery disease Lung cancer Vocal cord paralysis CASE 1 (4 of 4) Which of the following is the most likely cause of the patient’s dyspnea? Asthma COPD Coronary artery disease Lung cancer Vocal cord paralysis ANSWER: B This patient has progressively worsening dyspnea in the setting of tobacco use. Differentiating asthma from COPD can be challenging. In this patient, the pulmonary function tests reveal the presence of irreversible, fixed obstruction (ie, there is no improvement with bronchodilators). This finding is most consistent with COPD, although some patients with COPD may have evidence of a bronchodilator response. Patients with asthma generally exhibit partial reversibility of obstruction with bronchodilator administration. Another potential distinguishing feature is the temporal course of symptoms. Patients with COPD often have dyspnea with moderate levels of exertion, while patients with asthma primarily note dyspnea during exacerbations. Patients may have coexisting asthma and COPD, in which case they may meet criteria for a significant response to treatment with a bronchodilator (12% improvement in FEV1 or FVC), and the clinical presentation has elements of both conditions. Coronary artery disease can cause dyspnea, but this patient does not have other symptoms associated with underlying heart disease, such as chest pain or leg edema. Lung cancer may cause dyspnea, but it is rarely associated with bilateral wheezing. Instead, patients may have focal rhonchi or wheezing at the site of airway narrowing from lung cancer. The history of weight loss is concerning but not uncommon in patients with COPD. Vocal cord paralysis can lead to upper airway obstruction. That obstruction does not have the same effects on FEV1 and FVC as pulmonary airway obstruction, which occurs in COPD or asthma. Further, the wheeze noted in vocal cord paralysis is most prominent at the neck. Topic

CASE 2 (1 of 4) A 74-year-old man comes to clinic because for the past 4 months he has had a cough that is generally nonproductive, although at times there is scant white mucus. The cough is often worse in the morning. He has occasional wheezing, an acid taste in the back of his mouth, and rhinorrhea. He has not had fever, sore throat, or significant dyspnea. History includes coronary artery disease and mild hypertension; he had a myocardial infarction 2 years ago. He smoked cigarettes for 20 pack-years and stopped about 5 years ago. He is a widower. Topic

CASE 2 (2 of 4) On physical examination, there is no sinus tenderness, lymphadenopathy, or nasal abnormalities, and lungs are clear. Chest radiography shows no acute abnormalities. Topic

Esophagogastroduodenoscopy Pulmonary function tests CASE 2 (3 of 4) Which of the following is the least appropriate management option for the patient’s cough? Albuterol Ipratropium bromide Omeprazole Esophagogastroduodenoscopy Pulmonary function tests Topic

Esophagogastroduodenoscopy Pulmonary function tests CASE 2 (4 of 4) Which of the following is the least appropriate management option for the patient’s cough? Albuterol Ipratropium bromide Omeprazole Esophagogastroduodenoscopy Pulmonary function tests ANSWER: D This patient has symptoms that could be attributed to asthma (wheezing), postnasal drip (rhinorrhea), or GERD (acid taste, cough worse in the morning). Empiric therapy for any of these conditions would be reasonable. Pulmonary function tests could be performed to assess for asthma, but they may be negative if the patient does not have significant airway obstruction at the time of the test. Methacholine challenge test may be appropriate if pulmonary function tests are normal yet the index of suspicion for asthma remains high. A cough present for >2 months is considered chronic. The most common causes of chronic cough are asthma or COPD, postnasal drip, and gastroesophageal reflux. Chronic cough that develops after an upper respiratory infection usually resolves within 1 to 2 months. Examination of ears, nose, and throat and chest radiography will identify the cause of chronic cough in approximately 70% to 80% of patients. Irritants such as tobacco smoke should be eliminated. Empiric management is reasonable if there are no focal findings on physical examination or radiography. Response to treatment is usually seen in 2 to 8 weeks. Referral for esophagogastroduodenoscopy would be inappropriate at this time, because it is an invasive test that carries a risk of adverse events. If empiric therapy is ineffective, then it may be reasonable to refer the patient to a subspecialist for additional evaluation. Topic

CASE 3 (1 of 3) A 68-year-old woman comes to the office because of periods of dyspnea and wheezing that have worsened over the past 2 months. The episodes may occur 1 or 2 times a week. The patient tried using her grandson’s inhaler and believes it reduced her symptoms. She does not have cough, chest pain, leg swelling, fever, rash, or rhinorrhea. History includes hypercholesterolemia, osteoporosis, and type 2 diabetes. She does not smoke or drink alcohol. She is retired from working as a secretary. Topic

Which of the following is the most appropriate initial treatment? CASE 3 (2 of 3) Which of the following is the most appropriate initial treatment? Fluticasone Tiotropium Theophylline Albuterol Pulmonary rehabilitation Topic

Which of the following is the most appropriate initial treatment? CASE 3 (3 of 3) Which of the following is the most appropriate initial treatment? Fluticasone Tiotropium Theophylline Albuterol Pulmonary rehabilitation ANSWER: D This patient’s symptoms are consistent with intermittent asthma. Management of new-onset asthma is similar in older and younger patients. Patients with no significant cognitive impairment should be provided with an asthma action plan that includes self-monitoring of peak expiratory flow. Initial therapy with a short- acting β-agonist is recommended to ascertain patient response. If the patient rarely needs the short-acting agent, then it alone is adequate. If the patient routinely uses the inhaler >2 times in 1 week, inhaled corticosteroids should be added to reduce airway inflammation and delay progression to chronic, fixed obstruction. A short-acting agent alone will not adequately control symptoms in most older adults. Because the amount of systemic exposure to corticosteroids is relatively small with most inhalers, history of osteopenia or osteoporosis is not an absolute contraindication to corticosteroid use. Fluticasone and other inhaled corticosteroids are not indicated for initial treatment of intermittent asthma. Tiotropium is not warranted, because the patient does not have a diagnosis of COPD. Because theophylline has a low therapeutic index, it is generally used as a last resort for patients who are not responding to other therapies. Pulmonary rehabilitation comprises 10 to 15 outpatient visits to a pulmonary center, during which patient education and proper exercise technique are emphasized. It may be useful after a patient has started initial therapy, especially in cases of more severe disease. Topic

Managing Editor: Andrea N. Sherman, MS GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Margaret Pisani, MD and Kathleen M. Akgün, MD and questions by Nalaka Gooneratne, MD Managing Editor: Andrea N. Sherman, MS Copyright © 2014 American Geriatrics Society Slide 39