March/April 2012

Managing COPD in Elderly Patients

By Dana Saffel, PharmD, CGP, FASCP
Aging Well
Vol. 5 No. 2 P. 8

Chronic obstructive pulmonary disease (COPD), a common illness in the elderly, is a major cause of chronic morbidity and mortality. COPD is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response to the presence of noxious particles or gases in the airways and lungs. Exacerbations and comorbidities contribute to the overall severity in individual patients.

While inhaled cigarette smoke is the most common cause of COPD, other noxious particles such as smoke from biomass fuels and occupational dusts and chemicals can also contribute to the chronic inflammation encountered with COPD. This chronic inflammatory response may induce parenchymal tissue destruction (resulting in emphysema), and disrupt normal repair and defense mechanisms (resulting in small airway fibrosis). These pathological changes lead to air trapping and progressive airflow limitation, which result in the characteristic symptoms of COPD.

Symptoms of COPD include dyspnea, chronic cough, and/or sputum production. A clinical diagnosis can be made when a patient presents with these symptoms and/or a history of exposure to risk factors. Along with the inhalation of cigarette smoke or noxious particles, risk factors include age, gender, socioeconomic status, and a history of respiratory infections.

Diagnosis
Spirometry testing is required to make a confident diagnosis and can be used to classify the severity of airflow limitation. The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow limitation; the impact on the patient’s health status; and the risk of future events such as exacerbations, hospital admission, or death, in order to guide treatment.

With the patient blowing quickly into the spirometer mouthpiece and continuing to blow in an attempt to completely empty his or her lungs, a measurement of forced expiratory volume in one second (FEV1) can be compared with the total volume of air that was expelled, or forced vital capacity (FVC). Computing the ratio of FEV1/FVC can be used to assign a severity rating of airflow limitation.

The presence of a postbronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD. Prior to the 2011 update to the Global Initiative on Obstructive Lung Disease (GOLD) Guidelines, spirometry ratings were used to “stage” COPD as mild, moderate, severe, or very severe. While the classification scale remains the same, the 2011 GOLD update recognizes that at an individual patient level, the FEV1 is an unreliable marker of the severity of breathlessness, exercise limitation, and health status impairment and has changed the term “stage” to “grade” (see Table 1 below).

Spirometry is relatively easy to administer, but it does require that the patient be able to understand and comply with directions. Some patients with cognitive impairment or severe COPD may be unable to accomplish a successful spirometry test. Fortunately the assessment of COPD is also based on the patient’s level of symptoms, future risk of exacerbations, and the identification of comorbidities, allowing for a treatment plan to be developed without access to a spirometer. 

Recommended treatment options vary based on a measure of the impact of the patient’s symptoms and an assessment of the patient’s risk of having a serious adverse health event in the future. All individuals who smoke should be encouraged to quit. All COPD patients with breathlessness when walking at their own pace on level ground appear to benefit from pulmonary rehabilitation and maintenance of physical activity.

Influenza and pneumococcal vaccination should be offered to every COPD patient although they appear to be more effective in older patients and those with more severe disease or cardiac comorbidity. Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. However, none of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function.

GOLD Update
Previous COPD treatment guidelines have recommended medication management based on disease stage. However, the 2011 GOLD update now recommends that each pharmacological treatment be patient-specific and guided by symptom severity, drug availability, and the patient’s response. Patients are categorized into one of four groups based on a low or high risk of an exacerbation(s) and fewer or more symptoms (see Table 2 below).

Based on efficacy and side effects, inhaled bronchodilators are preferred over oral bronchodilators. Short-acting bronchodilators, such as ipratropium and albuterol, while widely available and frequently prescribed, should be limited to as-needed management of mild to moderate disease (Grade: GOLD 1 or GOLD 2) when patients have few symptoms and are at low risk for an exacerbation.

The mainstay of COPD treatment rests with long-acting bronchodilators, including the once-daily anticholinergic tiotropium; the twice-daily beta2-agonists sameterol, formoteral, and aformoterol; and the newly introduced once-daily beta2-agonist indacaterol. Long-acting agents are preferred over short-acting agents for both convenience and maintaining symptom control. As COPD progresses to the very severe stage (Grade: GOLD 4) it may be desirable to add an inhaled corticosteroid such as beclomethasone, budesonide, or fluticasone or the recently introduced oral phosphodiesterase4-inhibitor roflumilast to address chronic inflammation. Combining bronchodilators with different mechanisms and durations of actions may increase the degree of bronchodilation for equivalent or lesser side effects. 

When treatment is given by the inhaled route, attention to effective drug delivery and training on the specific device and associated inhalation technique is essential. The choice of inhalation device (eg, metered-dose inhaler, dry-powder inhaler, nebulized solution) will depend on availability, cost, the prescribing physician, the hospital formulary or respiratory treatment protocol prior to discharge, and the patient’s skills and ability.

Elderly COPD patients may have problems with physical coordination and/or may be cognitively impaired and unable to use a metered-dose inhaler or dry-powder inhaler. It is essential to ensure that inhalation device technique is correct, especially when disease worsening is detected, and to undertake efforts to correct the technique or change to a more appropriate device as part of symptom management.

*Information for this article was sourced from the Global Initiative for Chronic Obstructive Lung Disease report “Global Strategies for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” revised in 2011.

— Dana Saffel, PharmD, CGP, FASCP, is president and CEO of PharmaCare Strategies, a market development firm specializing in assisting pharmaceutical manufacturers and pharmacy providers to position key products in specialty channels such as long term care, managed care, Medicaid/Medicare, and hospital markets. She is active in areas of elder-focused professional organizations and serves as a frequent lecturer at national and regional meetings on disease management and healthcare policy.

Table 1. Classification of Airflow Limitation in COPD*

* For patients with FEV1/FVC < 0.70

Table 2. Pharmacologic Management of COPD

* Medications in this column can be used alone or in combination with other options in the first and second choice columns.