DR. UTTAM DASGUPTA
INTRODUCTION: Respiratory disease is a medical term that encompasses pathological conditions affecting the organs and tissues that makes gas exchange possible. The world population is rapidly ageing, As older people are more susceptible to chronic diseases, Increasing longevity has resulted in rising medical costs and increasing demands for health services. Promoting awareness of the special features of respiratory diseases in the elderly and implementing interventions early have a favourable clinical and economic impact. Age related associated diseases (comorbidity) , decline/loss of social support, atypical clinical presentations and special diagnostic problems make the elderly patient with respiratory disease, a complex client for a physician. The panorama of lung diseases is different in older and younger people and there are a number of immunological conditions and diseases induced by long-term exposure, which are substantially more prevalent in the older people as compared to younger persons. In this article, we shall be focusing on the commoner lung diseases in the elderly population that we encounter in our daily life.
Bronchial Asthma (as distinct from Cardiac Asthma which signifies Left Ventricular failure, a grave cardiac condition) is common in the elderly and is an increasingly serious health issue. Bronchial asthma is essentially a chronic airway inflammatory disorder characterized by airway hyper-reactivity to a number of non-specific stimuli leading to variable airway obstruction which is chiefly reversible with medications but which may become irreversible over years. Asthma in elderly is underdiagnosed and consequently undertreated. Diagnosis is complex as most of prevalence of a number of comorbidities and there is a significant degree of overlap in the elderly with another obstructive airway disease, called chronic obstructive pulmonary disease (COPD). There are additional concerns specifically for the elderly. Since old people tend to forget easily they may not take medications on time they may also may not understand the medication particularly inhalation techniques which is the essence of treatment in asthma. Asthma may start in childhood usually with a family history ( the early-onset asthma) and in these cases the elderly patients respond less well to usual treatment. In older people certain diseases need to be distinguished from asthma, particularly congestive heart failure, COPD, gastro-oesophageal reflux disease, vocal dysfunction, pulmonary embolism and sleep disorders. Although the general physician hardly resorts to measuring peak expiratory flow or rarely advises a spirometry for diagnosis and follow-up of asthmatics, they are of utmost importance in treating asthmatics and especially older asthmatics. The treatment is according to the severity of the disease and it is usually the same in both young and old asthmatics. However, the response in elderly is suboptimal. Cataracts and osteoporosis are common in the elderly and for this lowest possible doses of inhaled steroids are advocated. Measures to avoid triggers that precipitate asthma in older individuals should be avoided and these include avoidance of dust, fumes and smoke and certain drugs like beta-blockers like atenolol used to treat hypertension and ischaemic heart disease or non-steroidal anti-inflammatory agents like aspirin.commomnly used drugs like deriphylline should be used with caution as they may worsen already existing heart disease.The selection of the inhalation device is also important- dry powder inhalation is possibly better than meter-dose inhalation. When elderly patients cannot inhale, nebulizers are advisable. Annual influenza and 5 yearly pneumococcal vaccines are recommended in all elderly asthmatics above the age of 65. Adherence to therapy is important and this might be difficult to ensure in elderly people with who may have many other problems, vision loss, difficulty in hearing and movement together with depression. Underusage of inhaled corticosteroids due to apprehensions with steroid usage leads to increased mortality and morbidity in the elderly. Local adverse effects due to inhaled corticosteroids like hoarseness , cough and candidiasis is also more common in the elderly.
COPD is a respiratory disease with fixed airflow obstruction which is minimally reversible or irreversible with bronchodilators with little variation in day-to-day symptoms and is progressive. Typically wasted elderly people with history of smoking, presents with progressive shortness of breath, productive cough, decreased exercise tolerance. Spirometry should be routinely performed in suspected cases of COPD ( showing nearly fixed airway obstruction) particularly to distinguish it from asthma and also to monitor progress. COPD is usually a disease of the more elderly as distinct from asthma. Symptoms are usually persistent and progressive and history of smoking is almost always present. Although cessation of smoking is the single most important factor in preventing COPD, other potential targets for prevention include control of prenatal and childhood exposures to tobacco smoke, childhood infections, occupational and environmental dust and fumes. Some under-recognized factors like multiple chronic illnesses and psychosocial factors also present with diagnostic and management challenges. Systemic steroids have little value in management of COPD as distinct from management of asthma. If not properly managed at the early stage, elderly patients pass into respiratory failure. Acute exacerbations are frequent in elderly COPD patients and bronchial infections are usually the main cause. Risk factors for frequent exacerbations include increasing age, severe impairment in breathing capacity, frequent past exacerbations. Indications for hospital assessment or admission include: Marked increase in intensity of symptoms, onset of new signs ( cyanosis i.e. bluish discoloration of the tongue, nails, and peripheral oedema, i.e. swelling of the feet), failure to respond to optimal domiciliary treatment, new arrhythmias. To prevent exacerbations following are of proven efficacy- quitting smoking, medications like high dose long-acting Formoterol combined with inhaled corticosteroids, vaccines as in asthma, physical exercise, pulmonary rehabilitations which includes respiratory physiotherapy. Of questionable ef ficacy are Antibiotics, mucolytic agents, immunomodulators and antioxidants.. Exacerbations require treatment with ventilatory support (noninvasive), oxygen therapy.
CAP is an infection affecting the lung that is usually bacterial in origin with symptoms and signs of consolidation clinico-radiologically. It presents with shortness of breath, high fever and cough. However the older people frequently do not show classical presentation.Altered mental status are common in the elderly. Other features like a confused state, incontinence, episodes of falling, lethargy and weakness often delay diagnosis in the elderly resulting in greater mortality. CAP is usually treated in the outpatients department with antibiotics but those with severe disease and comorbid illnesses (usually the elderly subjects) are admitted to the hospital where they may require further treatment. The older patients often require ICU admission, have longer lengths of stay and exhibit higher mortality than the younger patients. CAP might often be a terminal event superimposed upon an underlying chronic debilitating health status. Intensive care and health support is required in the elderly sick patients. Prevention by flu and pneumococcal vaccine, chemoprophylaxis with antivirals should be thought of especially those with a high risk of CAP.
Pulmonary embolism (PE) :
PE is a clinically significant obstruction of part or all of the pulmonary vascular tree usually caused by a thrombus from a distant side. It usually presents with bloody sputum, sudden onset of shortness of breath, collapse especially in the elderly with poor cardiorespiratory reserve. It is a potentially fatal disease if left untreated. It’s incidence rises with age and it’s diagnosis is difficult. Non-invasive diagnostic work-up like D-dimer measurement, V/Q lung scan and helical CT usually diagnose the ailment and pulmonary angiography is usually not required. Major risk factor is usually surgery, malignancy(Pelvic, abdominal), lower limb problems and reduced mobility. The patient will require admission into an ICU with oxygen, fluids and and other intra-venous drugs to resolve the clot. Sometimes embolectomy may be required.
Sleep-disordered breathing (SDB) :
SDB is increasingly being recognized as a highly prevalent condition and present either in the classic way of obstructive sleep apnoea i.e. recurrent arousals from sleep, snoring and daytime sleepiness or combined with other frequent diseases such as heart failure, COPD, Diabetes or cerebrovasvcular disease. High clinical suspicion is required to diagnose SDB in elderly. Diagnostic criteria, clinical characteristics and treatment options ( cPAP in particular) are much less defined in elderly than in middle-aged persons.
Elderly patients often have comorbidities and other characteristics that makes selection of treatment daunting . Earlier, in elderly patients, non-small cell cancer lung were excluded from surgery. But now it is considered that surgery in fit elderly patients, gives similar benefits and toxicity as in nonelderly patients. Elderly subjects are subject to greater toxicity with adjuvant chemotherapy. Further studies are required to ensure rationality of various modalities in treatment of elderly lung cancer patients. Preventive measures include stopping cigarette smoking – 90% of lung cancer being smoking related. Stopping smoking decreases the risk but it still remains more than in nonsmokers. Risk of lung cancer is increased by asbestos exposure, arsenic and heavy metal exposure and coexisting idiopathic pulmonary fibrosis. Adenocarcinoma may not be smoking related.
We have discussed the common lung problems but there are a number of other respiratory diseases that we come across in elderly subjects. Diagnosis often is delayed due to obscure symptoms, associated illnesses and socioeconomic reasons facilitating negligence in treatment of elderly subjects. An early diagnosis and ethical management may go a long way to the treatment of respiratory diseases in elderly subjects.