5/24/19 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
5/24/19 Lung aging (decline in maximal lung Lung aging (decline in maximal lung function) begins: function) begins: A. in the 2 nd decade of life A. in the 2 nd decade of life B. in the 3 rd decade of life B. in the 3 rd decade of life C. in the 4 th decade of life C. in the 4 th decade of life D. when you sign up for Medicare D. when you sign up for Medicare Bush 2016, Burri 2006, Lange 2015 Maximal lung function begins to decline in Parenchymal Destruction & Reduced the 3 rd decade of life Elastic Recoil over Lifespan Onset of lung aging Lung cancer IPF COPD Childhood/ Young Mid- Mature Late Prenatal Adult life Adulthood Adulthood Adolescence (<20) (20-35) (35-50) (50-80) (>80) Parental smoking Asthma Respiratory Infections Pollution Bush 2016, Burri 2006, Lange 2015 Janssens 1999 2
5/24/19 Chest wall stiffening (extrinsic restriction): Respiratory Muscles Weaken (Sarcopenia) kyphosis and rib cage/cartilage calcification Leech 1990 Janssens 1999 With age, vital capacity ↓ and Aging & Pulmonary Disease “air trapping” (residual volume) ↑ Aspiration Dyspnea Lung cancer Combined Pulmonary Fibrosis & Emphysema (CPFE) Chronic Obstructive Pulmonary Disease (COPD) Idiopathic Pulmonary Fibrosis (IPF) Asthma-COPD overlap syndrome (ACOS) Asthma Bronchiectasis Janssens 1999 3
5/24/19 Aging & Pulmonary Disease Mr. F: 85 y/o m with Very severe COPD Aspiration (FEV1 30% predicted) Dyspnea Lung cancer Combined Pulmonary Fibrosis & Emphysema (CPFE) Chronic Obstructive Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Disease (COPD) Idiopathic Pulmonary Fibrosis (IPF) Asthma-COPD overlap syndrome (ACOS) Asthma Bronchiectasis Spirometry is confirmatory of COPD COPD diagnosis (not diagnostic by itself) Key: FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity • Symptoms: TLC = total lung capacity RV = residual volume • Dyspnea • Chronic cough/sputum Obstruction = FEV1/FVC <70% (actual) • Frequent respiratory tract FEV1 <80% (predicted) infections • Environment: • Smoke/pollution exposure • Typically >40 years old • Patient factors • Abnormal lung development • Accelerated lung aging Lange NEJM 2015 Postma NEJM 2015 4
5/24/19 Treatments Grade COPD Severity Based on FEV1 Based on (if FEV/FVC <70%) symptoms/exacerbations • GOLD 1: mild • mMRC breathlessness scale MMRC 3: Stop for breath after (Grades 0-4) or COPD FEV1 ≥ 80% predicted walking 100 meters or after a few assessment test (Score 0-40) minutes on level ground • GOLD 2: moderate Exacerbations 50% ≤ FEV1 < 80% A B • GOLD 3: severe 0 or 1 (no hospitalization) 30% ≤ FEV1 < 50% C D • GOLD 4: very severe ≥ 2 or ≥ 1 hospitalization FEV1 < 30% mMRC 0-1 mMRC ≥ 2 Symptoms CAT <10 CAT ≥ 10 GOLD 2019 Which of the following are true Which of the following is true regarding oxygen use in COPD? regarding oxygen use in COPD? A. Supplemental oxygen provides a mortality benefit if patients A. Supplemental oxygen provides a mortality benefit if patients are hypoxic with ambulation are hypoxic with ambulation B. Supplemental oxygen must be used >15 hours in order to B. Supplemental oxygen must be used >15 hours in order to provide a mortality benefit provide a mortality benefit C. Supplemental oxygen use isn’t useful for palliation in people C. Supplemental oxygen use isn’t useful for palliation in people who are not hypoxic who are not hypoxic D. Supplemental oxygen does not improve breathlessness during D. Supplemental oxygen does not improve breathlessness during exercise for mildly hypoxic and non-hypoxic people with COPD, exercise for mildly hypoxic and non-hypoxic people with COPD, not otherwise on oxygen not otherwise on oxygen Ekstrom Cochrane 2016 Cranston Cochran 2005 LOTT NEJM 2016 Uronis Thorax 2015 5
5/24/19 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 Thrush, hoarseness, pneumonia, increases risk • 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 Poll: I received training to counsel patients about correct inhaler use. • A. Yes • B. No • C. That’s not my job COPD Foundation app 6
5/24/19 Polypharmacy in Community-Dwelling Adults with COPD >4 meds 80.6% 58.4% Witt et al unpublished http://www.livebetter.org/ 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 7
5/24/19 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 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 8
5/24/19 Lung Cancer Screening with low dose Lung Cancer Screening with low dose CT scan has demonstrated CT scan has demonstrated • A. a 96.4% false positive rate • A. a 96.4% false positive rate • B. fewer deaths related to cancer compared to CXR screening • B. fewer deaths related to cancer compared to CXR screening (247per 100,000 person years compared to 309 per 100,000 (247per 100,000 person years compared to 309 per 100,000 person years in CXR) person years in CXR) • C. All-cause mortality is reduced by 6.7% as compared to chest • C. All-cause mortality is reduced by 6.7% as compared to chest radiography radiography • D. often inappropriate screening of groups not recommended to • D. often inappropriate screening of groups not recommended to be screened be screened • E. All of the above • E. All of the above Ma 2013 Huo 2017 National Lung Screening Trial Research Team 2011 USPSTF Grade B recommendation • Annual screening by Low • **Stop when life expectancy Dose CT in adults aged 55-80 is limited by comorbidities or patient would not want • 30 pack year smoking history curative lung surgery or and currently smoking radiation** or quit within 15 years • LDCT Shared Decision- Making: recommended but rarely done • Consider decision aid Redberg JAMA 2018 Brenner et al JAMA 2018 https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening https://effectivehealthcare.ahrq.gov/decision-aids/lung-cancer-screening/static/lung-cancer-screening-decision-aid.pdf 9
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