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Caring For Older Folks With COPD
Terri Fried, Carlos Fragoso, and Michael Rabow argue in the September 26, 2012 JAMA that older adults (age ~80 or above) with COPD and significant dyspnea are a distinct, complex group of patients with unique features and needs, and their doctors should think broadly and be willing to go "off-guidelines" in choosing therapies. Because these patients' dyspnea may impair all areas of their lives, doctors should take a multifaceted approach to assessing and treating older people with COPD.
Dyspnea in Older Adults With COPD Is Usually Multifactorial
By not accounting for age-related changes, the GOLD staging system misclassifies 28% of patients as "moderate" COPD who actually have severe COPD, authors say, citing an alternate staging system. This may be partly why older adults with moderate obstruction develop respiratory failure, usually considered part of severe COPD.
Although the ventilatory and diffusion impairments of COPD may be the dominant cause of dyspnea, other factors may often contribute in older adults:
- Older people with COPD often have sarcopenia (muscle wasting) of the respiratory and larger muscle groups, from COPD and / or any other comorbid illnesses, as well as malnutrition and deconditioning.
- Congestive heart failure, particularly diastolic CHF, is common in older people.
- In a postmortem study of people dying after hospitalization with a diagnosis of COPD exacerbation, 20% had pulmonary embolism. Small studies have suggested a high prevalence of PE in patients admitted with COPD exacerbations; others argue this risk is exaggerated.
- Polypharmacy: opioids and benzodiazepines may reduce ventilatory drive; corticosteroids and statins may cause muscle weakness; postural hypotension or central nervous system effects from antihypertensives and antidepressants can also interfere with aerobic capacity; all these contributors are plausible but not well studied.
- Anemia can reduce oxygen carrying capacity and worsen dyspnea.
- Depression, anxiety, chronic pain, and social isolation can all worsen the subjective experience of breathlessness.
Do Guidelines & Randomized Trial Data Apply to Older Patients with COPD?
These authors are skeptical about applying standard guidelines for COPD management broadly to older patients with COPD. Specifically, they are worried that:
- Higher rates of side effects and drug interactions from standard COPD treatments may make them more risky in older patients with multiple comorbidities, who were underrepresented in clinical trials approving COPD treatments. For example, anticholinergics can cause urinary retention, more commonly in older men. Authors also worry about the cardiovascular effects of tiotropium, which was exonerated of cardiovascular risk by the FDA mostly based on RCT data (UPLIFT) with relatively few elderly patients with comorbidities.
- Guideline-based treatment with inhalers will not be sufficient to relieve dyspnea in many older patients with COPD. They essentially advocate here for greater use of palliative therapies in people with dyspnea unresponsive to inhalers. One dyspnea reliever in particular the authors say is underused is morphine (and other opioids), due to "biases and fears" among clinicians. (Of course, the authors describe opioids in this same paper as a potential contributor to dyspnea, see above).
- They advocate for "symptom directed" treatment when insomnia, fatigue, and anorexia are contributors to poor quality of life. But they make no suggestion of how to treat these difficult symptoms, especially when potential treatments (such as Ambien at night, modafinil during the day, or testosterone replacement therapy) may have side effects too.
Besides morphine for relief of dyspnea, the only other concrete recommendation the authors make is for pulmonary rehabilitation, which includes lower and upper extremity exercise training, physiotherapy techniques, education, and psychosocial support. Guidelines have endorsed pulmonary rehab in most patients with COPD; the problem has always been getting insurers to pay for it at rates that induce providers to offer it. Consequently, pulmonary rehabilitation is rarely provided to patients with COPD (young or old) in practice.
Advance Directive Planning for Older Patients with COPD
There are understandable reasons why doctors don't talk to COPD patients about end-of-life care: COPD progression is unpredictable and variable, and doctors are notoriously inaccurate and on average, overly pessimistic when calculating the life expectancy of people with advanced COPD. Also, many patients don't want to talk about the end of their lives, preferring to stay positive.
There's a balance to be struck here somewhere, and the authors of this paper may have found it by proposing a list of questions you can use to naturally elicit your patient's desires in this challenging emotional and medical territory:
- What are the most distressing symptoms you are feeling?
- How much do you want to know about your prognosis, as I see it?
- Is there someone you trust to make your medical decisions for you, if you cannot make them for yourself?
- Remember the last time your COPD got so bad that it was hard to breathe. If that happened again, what would you hope for? What would you be most worried about?
- When you have your next COPD attack, if it is very severe and you need to be hospitalized or put on life support again to get through it, would you want that?
Terri Fried, Carlos Fragoso, and Michael Rabow. Caring for the Older Person With Chronic Obstructive Pulmonary Disease. JAMA 2012; 308(12): 1254-1263.