COPD is a lung disease characterized by a chronic blockage of lung airflow that interferes with normal breathing. The COPDs are irreversible. The most prevalent types of COPD are emphysema, which causes lungs to deteriorate over time, and chronic bronchitis, which causes a persistent cough with phlegm. The main cause of COPD is persistent smoking. Other risk factors include exposure to gases or fumes, pollution and second-hand smoke, and the use of a cooking fire without sufficient ventilation on a regular basis.
COPD is a huge public health concern around the world. COPD is one of the top causes of death in the United States. The disorder affects 10% of the population and its prevalence increases with age and behaviors like smoking. Prevalence studies of COPD show a rise in the incidence of the disease with advancement in age. It is projected that COPD will be the third primary source of death and incapacity by the year 2020 since the disorders requiring medical attention occurs late in life.
COPD is a major health problem in subjects above the age of 40 years. It is the cause of mortality and chronic morbidity worldwide. The prevalence of COPD increases with age and the complications brought about by chronic respiratory failures may be considered as geriatric conditions. Most cases of COPD among the elderly population remain undiagnosed due to the difficulty with the respiratory functions diagnostics and the atypical clinical presentations associated with the disorders. Consequently, the disease is undertreated and under-recognized in this category of subjects. (Incalzi, Scarlata, Pennazza, Santonico, & Pedone, 2014).
It was recently estimated that the prevalence rates of COPD in individuals older than 65 years was 14.2%. (Hanania, Sharma, & Sharafkhaneh, 2010).
Mortalities and comorbidities of COPD in the elderly
COPD is a major cause of illness and death globally. The risk factors contributing to this condition are smoking and age. Exacerbations associated with COPD and other comorbidities like diabetes mellitus, osteoporosis, cardiac diseases, and psychological disorders contribute to the illness's severity in individual patients. (Hillas, Perlikos, Tsiligianni, & Tzanakis, 2015).
The WHO approximates that COPD will be ranked the third cause of deaths globally by 2030, from the current ranking on the fifth position. Statistics indicate a continuing upward trend in mortalities related to COPD despite extensive research, health care efforts, and costs.
Diagnosis
It is hard to diagnose COPD in the elderly patients because the disease rarely presents alone. The disability and comorbidity of various origins contribute to the problem of recognition of the respiratory disorders. Additionally, at this age, the cognitive impairments and depression in subjects with hypoxemia and hypercapnia dominate the clinical scenes for the elderly patients. Severe exacerbations associated with COPD in the elderly may be recognized late as a result of the atypical presentation. (Jeannin, 2003).
The symptoms of COPD in the elderly population are not specific; hence the recognition and diagnosis of the disorders are delayed. Majority of the patients with these disorders possess a substantial history of smoking. Activity limitation and dyspnea are the common symptoms associated with COPD in old age. However, these symptoms may be associated with other pathological abnormalities such as cardiovascular disorders and other lung diseases. Wheezing and coughs may be other symptoms of COPD, but it may be related to other non-COPD such as congestive heart failure, bronchiectasis, and asthma. The physical diagnosis of COPD patients should be based on a history of exposure to noxious agents like cigarette smoking.
Spirometry testing is helpful in the confirmation of diagnosis and severity of the disease. Older patients can successfully perform the spirometry tests. Some, for example, those with cognitive impairments, limitations to vigorous respiratory efforts, and sedation, however, are unable to carry out these tests. (Mannino, Buist, & Vollmer, 2007). For older patients with cases of dementia, the diagnosis of the respiratory tract disorder, COPD, will be made purely on the clinical presentation. (Allen, 2003).
Pathophysiology of COPD in the elderly patients
Advancement in age affects the structure, regulation, and role of the respiratory system. The lungs and the chest walls undergo changes that can affect the duties of the respiratory system. Similarly, the elastic recoil, the primary determinant of the respiratory flow, diminishes with aging and causes an increased lung compliance at high lung volumes. Changes in the lung elastic properties and its matrix causes the reduction in the bronchiolar diameter and a resultant enlargement of the alveolar ducts. (Navaratnarajah & Jackson, 2013).These changes result in the decline in the expiratory flow and a decrease in the surface area for gas exchange
With advancement in age, the airways in the dependent sections close at higher volumes. At the respiratory circle, more airways are closed. The higher closing volume of the lower portions of the lungs increases the ventilation-perfusion disparity and accounts for a decline of oxygen pressure with age.
There is an evidence of the stiffening of the chest wall and a resultant decrease in compliance causing a decline in the dynamic and static compliance of the respiratory system. (Lalley, 2013).Cartilages are calcified, and muscle contraction accounts for the decreased chest expansion. The changes to the chest wall and the lung functionality increases the work of breathing.
The pathophysiology of COPD includes lung and airway inflammation, narrowing of the airways, remodeling and parenchymal lung destruction. New evidence suggests that the disorder is associated with systemic inflammation explaining the cachexia, cardiac comorbidity, and muscle weaknesses seen in patients. (Wouters, 2005). The physiological changes related to COPD are responsible for the continued impairment regarding exercise tolerance seen in many patients. Emphysema is characterized dilation of the airspace which results from the loss supporting tissue without the destruction of the alveolar walls which affects even the elderly non-smokers. (Sharma, Hanania, & Shim, 2009).Additionally, aging is a proinflammatory condition which is associated with a dysregulation of the immune system. Exaggerated tissue and systemic inflammation are vital to the pathogenesis of COPD hence the immunologic changes associated with the disease may overlap with those related to old age.
Treatment
The damage to the lungs as a result of COPD is permanent. The treatment, however, helps in slowing down the progression of the condition. An essential step in the treatment of COPD is the cessation of smoking. The action keeps the disease from getting worse. Although quitting smoking is a tough habit to stop, doctors can advise on the available nicotine replacement products and other medications to help in stopping the practice and handling relapses.
The primary goal of administering medications for elderly patients with COPD is to prevent exacerbations and maximize their pulmonary functions. The primary pharmacologic options ordered for the management of these diseases are the inhaled medication. The drugs in this category include the long-acting and short-acting beta agonists, short-acting and long-acting cholinergic antagonists, selective adrenergic agonists, and corticosteroids. Bronchodilators used as inhalants are used to relax the muscles along with an individual's airways, a step which relieves shortness of breath, coughing and makes it easy for a person to breath. Examples of these medications include albuterol, levalbuterol ipratropium, salmeterol, formoterol, and aclidinium among others.
COPD medications are administered by using pressurized metered dose inhalers (MDIs), nebulizers, and dry powder inhalers (DPIs). The pulmonary changes related with age, especially those that affect the inspiratory ability influences negatively on the methods of delivery of inhaled drugs. Hand-held inhalers, the DPIs and the MDIs, poses particular challenges for the elderly patients. The presence of cognitive impairment and physical disabilities associated with age especially with the elderly patients in the nursing home reduces the effectiveness of treatment of COPD using these devices. (Taffet, Donohue, & Altman, 2014).
Research indicates that the treatment goals of COPD in the elderly patients are not met. The use of complicated regimens for the treatment of patients in addition to hearing loss and poor eyesight in these patients makes it difficult for them to adhere to the procedures. The factors that affect the adherence to the medication regimens in an elderly patient include confusion regarding the drug, changes in treatment regimens, depression and anxiety, and the common morbidities of COPD patients in the nursing home. (Jimmy & Jose, 2011).
The decisions regarding the type of method for the administration of medications for the elderly should be based on individual patients depending on their preferences and capabilities. The step for choosing the appropriate method depends on an evaluation of the older patient’s ability to use the pressurized MDIs or DPIs. (Haidl, Heindl, Siemon, Bernacka, & Cloes, 2016). Patients who cannot be able to use hand-held inhalers after full instructions, those without the ability to coordinate between the inhalation and actuation of pressurized MDI, and those not able to produce highest inspiratory flow should be considered for the use of nebulizers. The use of nebulizers should be applied to the COPD patients who exhibit cognitive impairment or those with physical inabilities related to stroke, arthritis, Parkinson's disease, and any other manual weaknesses. (Bonini, & Usmani, 2015).
Other alternative treatments for COPD include the lung therapies, that is, the oxygen therapy and the pulmonary rehabilitation program. Oxygen therapy supplies additional oxygen to the lungs by use of portable units. The therapy improves the quality of life and can extend life. The pulmonary rehabilitation program, on the other hand, combines exercise, training, nutrition advice, education and counseling in the management of COPD patients. The therapy shortens hospitalizations and increases a patient's ability to participate in everyday activities improving their quality of lives.
Conclusion
COPD affects people of all ages but hits most on the elderly. Diagnosis of the disease may not be made on time in the older population. Early detection, leads to better management of the disease to contain the symptoms and ensure better lives for the elderly patients. Proper treatment of the disorders in an elderly patient requires the use of both the pharmacologic treatments and other alternative options like the cessation of smoking.
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