6/21/2019 Disclosures Pulmonary disease in • I have no relevant disclosures the older adult Leah J. Witt, MD @leahjwitt Assistant Clinical Professor Advances in Internal Medicine CME Course, 2019 Objectives • Understand the natural history of lung aging • Recognize the prevalence of common lung diseases with age What is “normal” lung • Develop a framework for approaching geriatric patients with the most common chronic lung disease of aging: chronic aging? obstructive pulmonary disease (COPD) • Diagnosis • Treatment • Geriatric Syndromes • Advance Care Planning & Palliative Care 1
6/21/2019 Lung aging (decline in maximal lung Maximal lung function begins to decline in the 3 rd decade of life function) begins: 48% A. in the 2nd decade of life Onset of lung aging Lung cancer B. in the 3 rd decade of life IPF 24% 24% C. in the 4 th decade of life COPD D. when you sign up for Medicare Childhood/ Young Mid- Mature Late 4% Prenatal Adolescence Adult life Adulthood Adulthood (<20) (20-35) (35-50) (50-80) (>80) e e e e f f f r l i l i l i a c Parental smoking Asthma f f f o o o i d e e e e d d d M a a a Respiratory Infections c c c e r e e o d d d f d d h p u n r t Pollution 2 3 4 n e e e g h h i h s t t t n n u n o i i i y n e h w Bush 2016, Burri 2006, Lange 2015 Parenchymal Destruction & Reduced Chest wall stiffening (extrinsic restriction): Elastic Recoil over Lifespan kyphosis and rib cage/cartilage calcification Leech 1990 Janssens 1999 2
6/21/2019 With age, vital capacity ↓ and Respiratory Muscles Weaken (Sarcopenia) “air trapping” (residual volume) ↑ Janssens 1999 Janssens 1999 Aging & Pulmonary Disease Aging & Pulmonary Disease Aspiration Aspiration Dyspnea Lung cancer Dyspnea Lung cancer Combined Pulmonary Fibrosis & Emphysema (CPFE) Combined Pulmonary Fibrosis & Emphysema (CPFE) Chronic Obstructive Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Disease (COPD) Idiopathic Pulmonary Fibrosis (IPF) Idiopathic Pulmonary Fibrosis (IPF) Asthma-COPD overlap syndrome (ACOS) Asthma-COPD overlap syndrome (ACOS) Asthma Bronchiectasis Asthma Bronchiectasis 3
6/21/2019 COPD diagnosis Mr. F: 85 y/o m with Very severe COPD • Symptoms: (FEV1 30% predicted) • Dyspnea • Chronic cough/sputum • Frequent respiratory tract infections • Environment: • Smoke/pollution exposure • Typically >40 years old • Patient factors • Abnormal lung development • Accelerated lung aging Lange NEJM 2015 Postma NEJM 2015 Spirometry is confirmatory of COPD Grade COPD Severity (not diagnostic by itself) Key: FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity Based on FEV1 Based on TLC = total lung capacity (if FEV/FVC <70%) symptoms/exacerbations RV = residual volume • GOLD 1: mild • mMRC breathlessness scale MMRC 3: Stop for breath after Obstruction = FEV1/FVC <70% (actual) (Grades 0-4) or COPD FEV1 ≥ 80% predicted walking 100 meters or after a few FEV1 <80% (predicted) assessment test (Score 0-40) minutes on level ground • GOLD 2: moderate 50% ≤ FEV1 < 80% Exacerbations A B • GOLD 3: severe 0 or 1 (no hospitalization) 30% ≤ FEV1 < 50% C D • GOLD 4: very severe ≥ 2 or ≥ 1 FEV1 < 30% hospitalization mMRC ≥ 2 mMRC 0-1 Symptoms CAT <10 CAT ≥ 10 GOLD 2019 4
6/21/2019 Which of the following are true Treatments regarding oxygen use in COPD? 42% A. Supplemental oxygen provides a mortality benefit if 35% patients are hypoxic with ambulation B. Supplemental oxygen must be used >15 hours in order to provide a mortality benefit 15% C. Supplemental oxygen use isn’t useful for palliation in 8% people who are not hypoxic D. Supplemental oxygen does not improve breathlessness during exercise for mildly hypoxic and non-hypoxic people with COPD, not otherwise on oxygen . . . . n d . . . . t s . i s i s v u e o e r m s o p u d n n n e n e e e g g g y y g y x y x x x o o o o l l l a a l a t t a t n n t n n e e e m m e m m e e e l l e p l p p l p p p p p u u u S u S S S Treatments Geriatrics & Inhaler challenges Side effects Incorrect Use • Impacts on mortality Anti-muscarinic agents • Error rate >40% for metered • Smoking cessation dose inhalers, dry powder Dry mouth, urinary retention inhalers slightly better • Oxygen use (if hypoxic at rest) • Common errors: coordination, • Immunizations (flu, pneumonia) Beta agonists no post-inhalation breath hold • Symptomatic Improvement/Exacerbation Prevention Tachycardia, arrhythmia, tremor Cost • Maintenance Inhalers (LAMA > LABA) • Cost- related non-adherence is Inhaled corticosteroids high (31%), cost >$20 month • Severe disease: ICS/LAMA/LABA triple therapy increases risk Thrush, hoarseness, pneumonia, • Avoid long-term oral steroids osteoporosis • Medicare Part D: high out-of- pocket costs ($900 yearly) • Pulmonary rehabilitation Castaldi 2010, Tseng 2017, Sanchis 2016, GOLD 2019 GOLD 2019 5
6/21/2019 Poll: I received training to counsel patients about correct inhaler use. A. Yes 59% B. No C. That’s not my job 41% 0% e s o b N Y o j y m t o n s t ’ a COPD Foundation app h T Polypharmacy in Community-Dwelling Adults with COPD >4 meds 80.6% 58.4% http://www.livebetter.org/ Witt et al unpublished 6
6/21/2019 COPD Geriatric Primary Care • Target comorbidities Morbid obesity, GERD, pulmonary hypertension, OSA, diastolic dysfunction and renal failure • Think about function Consider mobility aids, durable medical equipment, DMV placards and COPD = caregiving. Help people prepare for travel. Geriatric Primary Care • Osteoporosis Overlooked and undertreated: smoking & steroid use increase risk • Prognosticate and discuss advance care planning • Consider lung cancer screening Bon et al Ann Am Thorac Soc 2018 Prognosticating: BODE index Prognosticating: ADO index B MI , O bstruction , D yspnea & Exercise A ge, D yspnea, O struction 4 year survival: 0-2 points - 80% 3-4 points - 67% 5-6 points - 57% 7-10 points - 18% Mortality = 82% Score 9: 3 year mortality 64% Celli NEJM 2004 Puhan 2009 7
6/21/2019 Symptom Management & End of Life End of Life Care Care • 2006 VA study of patients with • Consider opiates for breathlessness COPD or lung cancer in the • Low dose opioids: not associated with increased admissions or last 6 months of life deaths in patients. • A fan directed at the face can be helpful • Patients with COPD: • twice the odds of ICU • Think outside of the box about making life easy admission • DMV disability placard • Costs were $4000 higher • Shower chair or other durable medical equipment (DME) • Much less use of palliative • Advance Care Planning (e.g. prepareforyourcare.org ) medicine • Symptom Management/Palliative Care referrals Ekstrom et al 2014 BMJ Au et al Archives of Internal Medicine 2006 Lung Cancer Screening with low dose USPSTF Grade B recommendation CT scan has demonstrated • Annual screening by Low • **Stop when life expectancy A. a 96.4% false positive rate 52% Dose CT in adults aged 55-80 is limited by comorbidities B. fewer deaths related to cancer compared to CXR or patient would not want • 30 pack year smoking history screening (247per 100,000 person years compared curative lung surgery or to 309 per 100,000 person years in CXR) and currently smoking radiation** 22% 22% C. All-cause mortality is reduced by 6.7% as compared or quit within 15 years • LDCT Shared Decision- to chest radiography Making: recommended but 4% D. often inappropriate screening of groups not 0% rarely done recommended to be screened • Consider decision aid e e . t . . . v a c . i . o E. All of the above r n e . n b e a c e a c u e v e i o d r h t t e c s i r s t o d s e f p e i t o t a Redberg JAMA 2018 e a y i l l l t r A s e i p a l r a l o f s t r % h r p Brenner et al JAMA 2018 o t m p 4 a a . e 6 e n 9 d i s a r u n e e w a https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening c t - f e l o f A l 8
6/21/2019 Mobility & Function https://effectivehealthcare.ahrq.gov/decision-aids/lung-cancer-screening/static/lung-cancer-screening-decision-aid.pdf Community-Dwelling Older Adults with Numerical age ≠ physiologic age COPD have more Geriatric Co-morbidities • People with chronic lung disease: • Have more muscle weakness (sarcopenia) • Are more frail (based on Fried Frailty phenotype: grip strength, walk speed, weight loss, exhaustion, physical activity) • Have a slower gait speed • Are more functionally impaired • Frailty predicts mortality better Fried 2001 Lahousse 2016 than FEV1 Fragoso 2012 Gosselink 1996 Witt et al unpublished 9
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