Overcoming gaps in the management of chronic obstructive pulmonary disease in older patients: new insights.

Chronic obstructive pulmonary disease (COPD) is a common disorder with a high prevalence among elderly men and women and an increasing mortality rate. Its diagnosis relies on spirometry, with a diagnostic cut-off value of a forced expiratory volume in 1 second (FEV(1))/forced vital capacity ratio of <0.7. This cut-off level has received some criticism because a ratio decline is part of normal advanced aging. Thus, clinicians must be vigilant in applying appropriate diagnostic criteria when managing elderly patients and may choose to use one or more of the alternative diagnostic values that have been created. It is important to remember that COPD is a systemic disorder with several extrapulmonary manifestations. Elderly patients with COPD are at an increased risk of cardiovascular events, osteoporosis, fractures, peripheral muscle wasting, depression and anxiety. Management of these patients requires a multidisciplinary approach and should begin with stratification of disease severity and prognostic information for each patient. Traditionally, FEV(1) has been used as a marker of COPD severity. However, indices such as the Modified Medical Research Council (MMRC) Dyspnoea Scale; the updated body mass, airflow, obstruction, dyspnoea and exercise (BODE) index; and the new age, dyspnoea, obstruction (ADO) index have been found to be better predictors of mortality in elderly patients. In addition to smoking cessation, supplemental oxygen and vaccines, management strategies such as patient education programmes--which have been shown to reduce hospital admissions--should not be overlooked. Pulmonary rehabilitation remains an underutilized treatment modality despite its demonstrated association with improvements in quality of life, reduced dyspnoea and increased exercise capacity. Studies have shown no correlation between age and outcomes in pulmonary rehabilitation, suggesting that age should not be an exclusion criterion. Although bronchodilators and corticosteroids remain the cornerstone of pharmaceutical management of COPD, their efficacy relies on correct medication administration. Inhaler technique should be frequently assessed in the elderly population and the choice of inhaler device needs to be tailored to the patients' needs, situation and preferences. Assessment and management of extrapulmonary co-morbidities of COPD should also be undertaken. Careful attention to the mental health of elderly patients with COPD is also vital, as they have high rates of depression and anxiety. Furthermore, elderly patients with severe COPD receive inadequate palliative care despite the elevated mortality risk associated with this illness. Early discussion about end-of-life care and advanced care planning is recommended.