SPECIAL CONSIDERATIONS IN THE ELDERLY PATIENT

The Effects of Aging on Lung Structure and Function

Growth of the segment of the population older than 65 years has led to intensified interest in understanding the biology of aging. This article is focused on age-related alterations in lung structure that produce predictable changes in physiologic function, both at rest and during exercise. Increased insight into the physiology of the healthy aging lung should ultimately lead to improved methods of lung function assessment in the elderly (defined as those older than 65 years) as well as better understanding of the manifestations and possibly even the treatment of geriatric lung disease.

Respiratory Disorders of the Elderly

Elderly are at increased risk for developing pulmonary disease over time. There has been an increase in the prevalence of and mortality from COPD and asthma in the industrialized world. In addition to the increase in these pulmonary diseases there are changes in the pulmonary function of the elderly due to structural changes with age, changes in gas exchange and changes in ventilatory response. This article reviews the epidemiology, diagnosis, prognosis, and therapy of asthma and briefly discusses the epidemiology and therapy of COPD with the emphasis on our elderly population.

Tracheostomy for Ventilator Dependence in the Elderly Patient: A Preliminary Report

With advances in medical technology and increasing numbers of elderly patients surviving acute intensive care unit admissions, otolaryngologic consultation regarding tracheostomy for ventilator-dependent patients is expected to continue increasing. However, established treatment guidelines and defined outcomes in terms of health status, quality of life, and medical costs are lacking in this emotionally delicate setting.

A retrospective case review of the outcomes of 19 elderly patients who underwent tracheostomy for ventilator dependence revealed that 14 had died within 40 days of surgery. The high number of deaths—which were caused by multiple organ failure, sepsis, and/or cardiopulmonary arrest—so soon after tracheostomy demands the implementation of outcomes research.

In this article, we introduce outcomes analysis as a means of assessing the utility of tracheostomy for ventilator dependence in the elderly and to advocate the establishment of a multidisciplinary palliative-care unit for this group of patients.

Current thoughts regarding treatment of chronic obstructive pulmonary disease

The available evidence indicates that pulmonary rehabilitation benefits patients with symptomatic COPD. The effect of pulmonary rehabilitation programs on health care use is promising but requires further investigation. In contrast, aerobic lower extremity training is of benefit in several areas of importance to patients with COPD. These areas include exercise endurance, perception of dyspnea, quality of life, and self-efficacy. The exact role of upper extremity exercise training programs requires further studies but should be used in patients who develop symptoms with arm activities. Psychological support improves the awareness of the patient and increases his or her understanding of the disease, but when used alone it is of limited value. Pulmonary rehabilitation when coupled with smoking cessation, optimization of blood gases, and medications offers the best treatment option for patients with symptomatic airflow obstruction.

Pulmonary rehabilitation improves exercise capacity in older elderly patients with COPD

Pulmonary rehabilitation has been shown to improve exercise capacity in patients with COPD. It has been suggested that this improvement applies to all age groups; however, to our knowledge, the effects of pulmonary rehabilitation on older elderly patients (> or = 75 years of age) have not been studied. We compared changes in 12-min walking distance (12MD) and self-assessment scores in 47 older elderly patients with moderate to severe COPD who completed inpatient or outpatient pulmonary rehabilitation with those achieved by 87 younger patients who participated in the same programs from 1987 to 1992. There were 28 older elderly individuals (mean +/- SEM, 78 +/- 1 years) in the outpatient group and 56 younger patients (64 +/- 1 years). There were no differences between older and younger outpatients with respect to FEV1, FEV1/FVC, maximum inspiratory pressure (PImax), baseline 12MD, or baseline self-assessment score. After outpatient pulmonary rehabilitation, 12MD and self-assessment scores improved significantly in both groups. Inpatients included 19 older elderly individuals (81 +/- 1 years) who were also similar to the 31 younger inpatients (64 +/- 1 years) in FEV1, FEV1/FVC, PImax, and baseline self-assessment score, but they tended to be more limited in terms of baseline 12MD (p = 0.09). After inpatient pulmonary rehabilitation, significant improvements in 12MD and self-assessment were seen in both groups. We conclude that comprehensive outpatient and inpatient pulmonary rehabilitation programs are as beneficial in older elderly patients with COPD as they are in younger patients with similar lung function abnormalities. Patients 75 years of age or older should be considered for comprehensive pulmonary rehabilitation.