Use of Antibiotics in Elderly Patients with Exacerbated COPD: The OLD-Chronic Obstructive Pulmonary Disease Study

Determinants of chronic obstructive pulmonary disease severity in the late-elderly differ from those in younger patients

BACKGROUND

Although the age range of chronic obstructive pulmonary disease (COPD) patients is broad, few studies have focused on the effects of age on disease characteristics.

METHODS

Keio University and affiliated hospitals established an observational COPD cohort. Patients were assessed using high resolution computed tomography (CT) to quantify emphysema, health status using the COPD assessment test (CAT) and the St. George's Respiratory Questionnaire (SGRQ), spirometry, echocardiogram, dual X-ray absorption of bone, biomarkers and comorbid diagnoses. We examined the characteristics of COPD patients aged 75 and over compared with patients below 75.

RESULTS

A total of 443 patients comprising 252 patients aged <75 years and 191 patients aged ≥75 years, were enrolled. Emphysematous changes on CT and prevalence of possible pulmonary hypertension were greater in late-elderly patients. The slope of the relationship between CT emphysema densitometry score and forced expiratory volume in 1 s was significantly less steep in the late-elderly than the younger patients (p = 0.002). CAT and total SGRQ scores and the frequency of long-term oxygen therapy were significantly higher in the late-elderly with moderate airflow obstruction compared to those of the younger in the same grade, although the opposite was seen in late-elderly patients with very severe airflow obstruction. Hypertension, aortic aneurysm, prostatic hypertrophy, anemia, and cataract are more prevalent in late-elderly patients.

CONCLUSIONS

Elderly COPD patients show a varied age-related pattern of disease that warrants specific attention in clinical practice above and beyond assessment of airflow limitation. Trial registration Clinical trial registered with the University Hospital Medical Information Network (UMIN000003470, April 10, 2010).

Previous outpatient antibiotic use in patients admitted to hospital for COPD exacerbations: room for improvement

PURPOSE

Several studies have analyzed factors associated to hospitalization in chronic obstructive pulmonary disease (COPD) patients. However, data are lacking on the quality of treatment received by patients prior to hospital admission. The present study analyzed how often patients requiring hospitalization for a COPD exacerbation had received previous treatment for the exacerbation, particularly antibiotics.

METHODS

This was a multicenter, cross-sectional, observational study conducted in 30 Spanish hospitals among COPD patients aged >40 years who were hospitalized for an acute exacerbation. Patients were grouped according to whether or not they had received treatment prior to admission and, subsequently, according to whether or not they had received antibiotics. Patient eligibility for antibiotic therapy was assessed using both national and European guidelines.

RESULTS

The study population consisted of 298 patients, of which 277 (93 %) were men, with a mean [standard deviation (SD)] age of 69.1 (9.5) years. One hundred and thirty-three patients (45 %) had received treatment prior to admission; among these, 76/133 (57 %) had received antibiotic therapy. However, 81-91 % of these patients fulfilled criteria for this therapy. Antibiotic use was significantly associated with yellow or green-yellow sputum prior to the exacerbation, a higher number of exacerbations in the previous year, more visits to emergency departments, and bronchiectasis. On the other hand, 10-20 % of patients who did receive antibiotics were not eligible for this therapy according to guidelines.

CONCLUSIONS

This study demonstrates a low rate of previous outpatient treatment and antibiotic use among patients with a COPD exacerbation requiring hospital admission.

Practical management problems of chronic obstructive pulmonary disease in the elderly: acute exacerbations

PURPOSE OF REVIEW

Acute exacerbations of chronic obstructive pulmonary disease (ECOPDs) have numerous causes and are associated with increased mortality and hospitalization, especially in older patients. The urgent need to identify and enable timely treatment of ECOPDs is a necessity for physicians worldwide. This review will highlight the causes and optimal combinations of available treatments for such events in older populations.

RECENT FINDINGS

The exact definition of exacerbations is lacking; however, it is agreed that such events are considered episodes of worsening of symptoms, leading to morbidity and death. The aging process is a consistent determinant for ECOPD events and is associated with worsening of COPD stages. The incidence of ECOPD rises across the worsening stages of COPD. Studies have shown that the frequency of exacerbations increases with age and correlated clinical outcomes are poorer than in younger patients. The risk of mortality has also been shown to be significantly higher after a hospital admission following an acute exacerbation. At the moment, the need to rapidly and correctly treat acute exacerbations is crucially important in the rapidly growing elderly population.

SUMMARY

ECOPDs are extremely dangerous events for older patients with severe stages of COPD. There is an urgent need to identify risk factors, identify tolerable treatment guidelines and manage acute exacerbations in older patients with COPD.

Predictors of long-term survival in elderly patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

There is a paucity of survival data regarding the prognosis of elderly patients following acute exacerbations of COPD (AECOPD). We undertook a study to examine long-term mortality rates and to identify clinical and laboratory predictors of these outcomes.

METHODS

A retrospective cohort study was conducted of 786 consecutive elderly (>65 years) patients admitted to general medicine acute-care wards for AECOPD. Factors determining short- and long-term mortality were analysed.

RESULTS

The mean (+/-SD) age of the study population was 75.8 +/- 7.3 years (range 65-100 years). The in-hospital mortality rate for the entire cohort was 7.25%. The risk of mortality at 1, 3 and 5 years was 28%, 47% and 54%, respectively. In univariate analysis age (hazard ratio 1.52; 95% confidence interval: 1.23-1.91), FEV(1) (1.45; 1.73-2.35), active cancer (1.23; 1.64-2.32), current smoking (1.74; 1.35-2.11), ischaemic heart disease (1.58; 1.28-2.02), congestive heart failure (1.55; 1.23-2.26) and maintenance use of oral glucocorticosteroids (1.58; 1.11-2.79) were significantly associated with mortality. In multivariate analysis, only current smoking (1.89; 1.18-1.93), ischaemic heart disease (1.41; 1.07-1.68), PaCO(2) on admission (1.49; 1.03-1.60), hospital readmission (2.23; 1.40-2.18) and FEV(1) (1.41; 1.12-1.54) were independent predictors of mortality.

CONCLUSIONS

This study provides new insights into the predictive factors associated with long-term prognosis in elderly patients admitted for acute exacerbations of COPD, which differ from those previously identified for younger patients.

From Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to current clinical practice : an overview of the pharmacological therapy of stable chronic obstructive pulmonary disorder

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been promulgated to improve the management of chronic obstructive pulmonary disorder (COPD).

OBJECTIVE

To evaluate the extent to which the current therapeutic approach to COPD conforms to GOLD guidelines.

METHODS

This was a multicentre observational study of elderly COPD patients enrolled for acute care in general medicine or geriatric wards in tertiary hospitals in Italy in April 2002. Our series consisted of 471 patients >64 years of age consecutively admitted for acute exacerbations of COPD to wards participating in the study. Data describing drugs used prior to exacerbation and prescribed at discharge were collected using a standardised protocol. Changes in prescription at discharge were then compared with home therapy. Demographic variables and indices of COPD severity and co-morbidity were tested as potential correlates for the main outcome measure 'variant prescription', i.e. prescription of a drug considered as a third-line treatment (e.g. methylxanthines) or not recommended (e.g. mucolytics) by GOLD guidelines. The correlation was assessed first by univariate analysis and then by logistic regression analysis.

RESULTS

At discharge, prescription of short-acting beta(2)-adrenoceptor agonists had decreased from 26.3% to 14.0%. Conversely, increases in prescription of long-actingbeta(2)-adrenoceptor agonists (from 43.1% to 68.4%), inhaled corticosteroids (50.7% to 69.6%) and anticholinergics (17.2% to 22.3%) were seen. The rate of use of methylxanthines was 49.7% before admission and 44.8% at discharge, with previous use being the main correlate of discharge prescription for this class of drugs (odds ratio [OR] = 4.35; 95% CI 2.88, 6.54). The rate of use of mucolytics was 26.3% before admission and 26.8% at discharge, with use of mucolytics prior to admission being the only correlate of discharge prescription (OR = 4.10; 95% CI 2.47, 6.82).

CONCLUSIONS

Hospitalisation resulted in increased adherence to GOLD guidelines in patients with COPD, but the rate of use of anticholinergics was distinctly low and that of methylxanthines and mucolytics surprisingly high. A carry-over effect (i.e. of therapy prescribed by general practitioners on that prescribed by hospital-based physicians) likely accounts for most of the 'variant prescriptions' seen at discharge from the acute care hospital.