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Standard Guidelines for Treating Chronic Obstructive Pulmonary Disease May Not Be Appropriate for Older Adults with Additional Health Problems

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Summary of this Report
Chronic Obstructive Pulmonary Disease (COPD) is a common health problem and a leading cause of death in the United States. It causes shortness of breath, wheezing, and related symptoms. When more advanced, it can cause respiratory failure -- an inability to breathe well enough to get the oxygen your body needs.

Early on, the symptoms of COPD may not be noticeable, but they worsen over time --so getting the right treatment is essential. It’s very important that older adults who have the disorder get treatment tailored to their unique care needs, because standard medical guidelines for treating the disorder don’t always take into account older COPD patients’ other health problems and care needs, according to an article in the September 26, 2012 issue of the Journal of the American Medical Association (JAMA).

There are a number of different types of COPD, but the two most common are emphysema and chronic bronchitis. With both of these conditions, the airways in your lungs get inflamed and start producing too much phlegm (mucus). The inflammation and extra phlegm narrow the openings in your airways, making it harder for you to get the air you need. With emphysema, the tiny air sacs in your lungs are damaged as well.

Why Following Standard Guidelines for Treating COPD May Not Be Right For Older Adults
Smoking causes more than 80 percent of all cases of COPD, and the most important thing you can do if you have COPD and smoke, is quit smoking. For older adults, medical treatment that’s tailored to your needs is also essential, note the authors of the JAMA report, Terri R. Fried, MD, Carlos A. Vaz Fragoso, MD, and Michael W. Rabow, MD. Many older people with COPD have additional health problems that are increasingly common with age–- such as heart failure, malnutrition, and anxiety. And these conditions can both make COPD worse and complicate care, Drs. Fried, Vaz Fragoso, and Rabow explain.

Having both COPD and other health problems at the same time can make COPD worse and complicate care for a number of reasons. Medications can cause side effects, and if an older adult with COPD is taking multiple medications -- for the disorder and for other health problems -- he or she is more likely to have medication side effects. At the same time, medications can interact in ways that can be dangerous, so taking medications for COPD and additional health problems can increase risks of dangerous medication interactions. In light of this, trying to treat every disorder that such a patient has may harm more than help, Drs. Fried, Vaz Fragoso, and Rabow write. “[Meeting] the many needs of older patients with COPD … requires that clinicians supplement guideline-recommended care with treatment decision-making that takes into account the older person’s” other health problems and priorities, they explain.

Instead of trying to maximize treatment for all of the disorders that an older patient with COPD and numerous other health problems has, it’s often better for the patient (or his caregiver, or both) to talk with his or her healthcare providers, and determine which treatments would improve the quality of his or her life the most. This way, his or her healthcare providers can focus on providing those treatments. Patients with COPD and other disorders should also decide what kind of care they would like to have at the end of their lives, and share this with their healthcare providers, Drs. Fried, Vaz Fragoso, and Rabow add.

An Older Patient’s Experience
To illustrate why standard care guidelines for COPD may not be appropriate for older adults who have COPD and additional health problems, the JAMA article describes the case of an 81-year-old man with the breathing disorder in addition to a wide range of others. Identified as “Mr. V.” to protect his privacy, the man had high blood pressure, depression, heart failure, diabetes, glaucoma and several other health problems along with COPD. A widower living in an assisted living facility, he was taking more than a dozen different medications and getting oxygen. Despite all the medications and treatments, he developed severe shortness of breath and respiratory distress, was admitted to the intensive care unit (ICU), and hospitalized for treatment for four days. By the end of the fourth day, he was able to return to the assisted living facility, but was in poorer health than before he was hospitalized.

Older Patients With COPD And Other Disorders Have Unique Care Needs
The authors describe the ways that not only Mr. V’s COPD, but also his other health problems and the many medications he was taking, contributed to his developing shortness of breath and respiratory failure. In addition to the COPD, for example, his heart failure, diabetes, malnourishment, and advanced age likely contributed to his difficulty breathing, including weakening the muscles that play an important role in breathing, Drs. Fried, Vaz Fragoso, and Rabow explain. Medications Mr. V was taking – such as statins and corticosteroids – can also weaken muscles that play key roles in breathing, and may have contributed as well.

At the same time, there were treatments – such as pulmonary rehabilitation -- that Mr. V didn’t get, that could have lowered his risk of having respiratory failure and related problems, the authors add. “Pulmonary rehabilitation should be a critical component of Mr. V’s management because it addresses many of the contributors to” shortness of breath and other symptoms, the authors write. 

“As Mr. V’s experience illustrates, (standard) guidelines applied to older patients with (shortness of breath) and respiratory failure are limited for a number of reasons,” Drs. Fried, Vaz Fragoso and Rabow explain. Instead of relying exclusively on such guidelines, complex older patients with COPD need individualized care, including honest discussions about preferences for end-of-life care. 

Managing COPD in older adults with multiple health problems “requires a process of shared decision making, wherein patients identify the health outcome(s) of greatest important to them,” the authors emphasize.

What You Can Do
Talk to your healthcare provider about what you want most from the care you get. Sometimes, treatments can cause side effects that outweigh their benefits. If a drug that could extend your life several months makes you so dizzy that you run a high risk of falling and, as a result, can no longer live independently, but your independence is very important to you, you may want to stop taking the medication.    

There is no “right” or “wrong” choice in cases like that; the decision will depend on what matters most to you. You may wish to make these care decisions on your own; or with help from a caregiver, or your healthcare providers, or both. Or you may opt to have a caregiver, or a professional, or both, make decisions for you.  To ensure that you will get the care you want, even at the end of life, you should also put your wishes in writing and share them with your relatives, caregivers, and healthcare providers.

This summary is from the full report titled, “Caring for the Older Person with Chronic Obstructive Pulmonary Disease.” It appears in the October 26, 2012 issue of the Journal of the American Medical Association. The report is authored by Terri R. Fried, MD; Carlos A. Vaz Fragoso, MD; and Michael W. Rabow, MD.