Journal of Gerontological Nursing

Geropharmacology 

Chronic Obstructive Pulmonary Disease in Older Adults: Part I: Case Study

Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP; Heather Cook, PharmD

Abstract

Chronic obstructive pulmonary disease (COPD) is a distressing respiratory disease that may greatly impact a patient's quality of life. Although many treatment options exist, the Global Initiative for Chronic Obstructive Lung Disease Guidelines outline management strategies based on severity of daily symptoms and exacerbations. Although it is important to weigh the risks and benefits of medication use, involvement of patients in their overall care plan is imperative to optimal outcomes. According to recent studies, the prevalence of COPD in older adults is increasing, along with the complexity of care due to comorbidities, drug interactions, and side effects. A thorough evaluation of a patient case provides insight into the everyday challenges of COPD management. [Journal of Gerontological Nursing, 44(7), 10–14.]

Abstract

Chronic obstructive pulmonary disease (COPD) is a distressing respiratory disease that may greatly impact a patient's quality of life. Although many treatment options exist, the Global Initiative for Chronic Obstructive Lung Disease Guidelines outline management strategies based on severity of daily symptoms and exacerbations. Although it is important to weigh the risks and benefits of medication use, involvement of patients in their overall care plan is imperative to optimal outcomes. According to recent studies, the prevalence of COPD in older adults is increasing, along with the complexity of care due to comorbidities, drug interactions, and side effects. A thorough evaluation of a patient case provides insight into the everyday challenges of COPD management. [Journal of Gerontological Nursing, 44(7), 10–14.]

Increasing age is associated with an increased prevalence of chronic obstructive pulmonary disease (COPD), a disease characterized by persistent respiratory symptoms and airflow limitations, which may greatly impact a patient's quality of life (World Health Organization [WHO], n.d.). Increasing severity, usually occurring later in life, often requires medical attention. Although many treatment options are available, COPD is expected to become the third leading cause of death and disability worldwide by the year 2020 (WHO, n.d.). The prevalence of COPD in individuals 65 and older is estimated to be 14.2% (11% to 18%), compared with 9.9% (8.2% to 11.8%) in individuals 40 and older, with a two-fold increase in the prevalence of COPD observed for every 10-year increment in age (Halbert et al., 2006). To complicate the situation further, studies have shown up to 40% of patients with COPD exacerbations do not receive guideline-directed therapies, and up to 50% receive at least one medication that is deemed potentially harmful (Lindenauer et al., 2006; Mularski et al., 2006). A greater emphasis needs to be placed on the treatment of COPD in older adults, while accounting for patient- and agent-related variables, such as comorbidities, adverse effects, and cost.

Case Study

AB is a 93-year-old woman with a long history of COPD. She has a raspy voice, having smoked for more than 40 years. She quit smoking at age 65, when her first grandchild was born, which gave her the motivation to stop smoking. AB was diagnosed with COPD at age 57. She reports chronic dyspnea, wheezing, and chest tightness, which have become worse over the past 1 to 2 years. Because her symptoms have worsened, she is worried about not being able to play with her grandchildren. She is concerned about her dyspnea and cough while engaging in slightly strenuous activity, such as walking in a hurry on level ground. She uses 4 L of oxygen at home, but when she goes somewhere with her oxygen tank, she uses 1 L via nasal cannula. It is also noted that there may be an anxiety component to her COPD.

Of note, AB has had multiple visits to the emergency department due to COPD chest pain, most recently in the past month. Per the discharge note, AB:

was admitted for COPD exacerbation and started on steroid therapy and DuoNeb®. She has overall very poor lung status complicated with diastolic heart failure; however, subsequently she is improved…and is now in stable condition to be discharged. She will go home on a steroid taper course.

AB lives alone at a senior living facility. Her son is actively involved in her care. He organizes her pillbox and she independently manages her inhalers and nebulizers. However, she notes that she only uses the nebulizers if set up by the homecare nurse. Regarding her inhalers, it is unclear which she uses, as she has both Proair® and Advair® HFA. Her son has expressed concerns with methylprednisolone and multiple daily doses. Per the pharmacy refill records, she has not been using the Advair regularly. AB's current diagnoses and medical history are presented in Table 1.

Medical History of Presented Case Study

Table 1:

Medical History of Presented Case Study

COPD Severity Assessment

Many tools can be used to diagnose, as well as assess, the severity of COPD. Of note, spirometry is required to make the definitive diagnosis of COPD; the presence of a post-bronchodilator forced expiratory volume/forced vital capacity (FEV1/FVC) < 0.70 confirms the presence of persistent airflow limitation. AB would be classified as GOLD 3, group C (Global Initiative for Chronic Obstructive Lung Disease, 2018). Table 2 provides the GOLD classifications and Figure 1 provides the grouping. The grouping is based on exacerbation history and patient assessment of symptom severity. The COPD assessment test (CAT; American Thoracic Society, 2016) and the Modified Medical Research Council Dyspnea Scale (mMRC; Mahler, n.d.) are two patient-centered assessment tools used to asses symptom severity. The GOLD classification facilitates consideration of individual therapies and helps guide escalation and de-escalation of therapeutic strategies for a specific patient.

Gold Classification

Table 2:

Gold Classification

ABCD assessment of chronic obstructive pulmonary disease (COPD) (American Thoracic Society, 2016; Global Initiative for Chronic Obstructive Lung Disease, 2018; Mahler, n.d.).Note. mMRC = Modified Medical Research Council Dyspnea Scale; CAT = COPD assessment test.Adapted from Global Initiative for Chronic Obstructive Lung Disease. (2017). Pocket guide to COPD diagnosis, management, and prevention. Retrieved from https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf

Figure 1.

ABCD assessment of chronic obstructive pulmonary disease (COPD) (American Thoracic Society, 2016; Global Initiative for Chronic Obstructive Lung Disease, 2018; Mahler, n.d.).

Note. mMRC = Modified Medical Research Council Dyspnea Scale; CAT = COPD assessment test.

Adapted from Global Initiative for Chronic Obstructive Lung Disease. (2017). Pocket guide to COPD diagnosis, management, and prevention. Retrieved from https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf

Treatment Approaches

Nonpharmacological

When treating patients and their support team (e.g., family members, caregivers), education and self-management (i.e., daily review of symptoms) with a COPD action plan is essential. An action plan helps empower patients by enabling them to play a vital role in their personal care and also assists the clinical team in tailoring treatment approaches. An example of a useful tool is the COPD Action Plan (American Lung Association, 2015) (access http://www.lung.org/assets/documents/copd/copd-action-plan.pdf). Additional interventions that are critical to reduce disease progression and future exacerbations include smoking cessation, immunizations, and physical activity.

Pharmacological

There are numerous pharmacological options for treating COPD, and Figure 2 highlights the different approaches based on severity assessment (Global Initiative for Chronic Obstructive Lung Disease, 2018). Ultimately, the choice of inhaler device must be patient centered and depend on access, cost, prescriber, and, most importantly, the patient's ability to use it. Prescribers should be open to speaking with patients to determine preferences, taking into consideration methods to increase efficacy and decrease toxicity.

Treatment approaches for chronic obstructive pulmonary disease based on severity assessment.Note. LAMA = long-acting muscarinic antagonists; LABA = long-acting beta2-agonists; ICS = inhaled corticosteroid; FEV = forced expiratory volume.Reprinted with permission from Global Initiative for Chronic Obstructive Lung Disease. (2017). Pocket guide to COPD diagnosis, management, and prevention. Retrieved from https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf

Figure 2.

Treatment approaches for chronic obstructive pulmonary disease based on severity assessment.

Note. LAMA = long-acting muscarinic antagonists; LABA = long-acting beta2-agonists; ICS = inhaled corticosteroid; FEV = forced expiratory volume.

Reprinted with permission from Global Initiative for Chronic Obstructive Lung Disease. (2017). Pocket guide to COPD diagnosis, management, and prevention. Retrieved from https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf

According to the GOLD guidelines (Global Initiative for Chronic Obstructive Lung Disease, 2018), long-acting muscarinic antagonists (LAMAs) are preferred over long-acting beta2-agonists (LABAs) due to superior effects in exacerbation prevention. Yet, LABAs have been shown to “significantly improve FEV1 and lung volumes, dyspnea, health status, exacerbation rate and number of hospitalizations, but have no effect on mortality or rate of decline of lung function” (Global Initiative for Chronic Obstructive Lung Disease, 2018, p. 48). Although oral glucocorticoid agents play a role in the acute management of exacerbations, they have no role in the chronic daily treatment of COPD because of a lack of benefit balanced against a high rate of systemic complications (e.g., impaired glucose, bone health).

Referring to the case study, AB is already using Advair, a LABA + inhaled corticosteroid (ICS), along with Spiriva®, a LAMA. This is the preferred therapeutic regimen according to the treatment algorithm above; however, she continues to have worsening symptoms. At this time, a trained medical professional (e.g., physician, pharmacist, nurse practitioner) should assess AB's inhaler technique and adherence. She should be counseled on proper technique, as well as the importance of taking maintenance medications daily as indicated. Medication adherence should always be addressed before prescribing additional medications. Barriers to optimal medication adherence may include, but are not limited to: cost, concurrent health conditions (e.g., tremors or arthritis, which make inhaler coordination more difficult), and cognitive impairment. AB should be administered her annual flu vaccine and both pneumonia vaccines as appropriate. In addition, deep breathing exercises may be recommended for the potential anxiety component of her COPD.

As the efficacy aspects are balanced, it is imperative to monitor for side effects that may impede adherence to treatment approaches or exacerbation of comorbidities. For instance, in a patient like AB, the stimulation of beta2-adrenergic receptors can produce resting sinus tachycardia and has the potential to precipitate cardiac rhythm disturbances. Inhaled anticholinergic drugs can cause xerostomia, which can affect appetite and lead to failure to thrive. Routine follow up and involvement of the patient in the care plan is essential for effective medication management.

Trelegy Ellipta®. The U.S. Food and Drug Administration approved fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) (Trelegy Ellipta) for maintenance treatment of patients with COPD (Pharmacy Times, 2017). This treatment is a combination of an ICS, LAMA, and LABA and the first once-daily product approved in the United States that combines three active molecules in a single inhaler for the treatment of COPD.

Roflumilast (Daliresp®). Roflumilast and the active metabolite, roflumilast N-oxide, selectively inhibit phosphodiesterase 4, a major cyclic adenosine monophosphate (AMP) metabolizing enzyme in lung tissue. The specific mechanism of roflumilast activity in COPD is not well defined; it is thought to be associated with increased levels of intracellular cyclic AMP in lung cells and reduced neutrophil and eosinophil cell counts in the lungs. Roflumilast reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations. The effects on lung function are also seen when roflumilast is added to long-acting bronchodilators, and in patients who are not controlled on fixed dose LABA/ICS combinations. In the intention-to-treat population, the frequency of moderate-to-severe exacerbations was 13.2% lower in the roflumilast group than in the placebo group in the Poisson regression analysis (rate ratio [RR] = 0.868, 95% confidence interval (CI) [0.735–1.002], p = 0.0529), and was 14.2% lower (RR = 0.858, 95% CI [0.740–0.995], p = 0.0424) in the negative binomial regression analysis (Martinez et al., 2015). No study has compared roflumilast with an ICS.

The most frequent adverse effects of this once daily oral agent are diarrhea, nausea, reduced appetite, weight loss, abdominal pain, sleep disturbance, and headache. Adverse effects seem to occur early during treatment, are reversible, and diminish over time with continued treatment. In controlled studies, an average unexplained weight loss of 2 kg (4.4 lb) has been seen and weight monitoring during treatment is advised in addition to avoiding roflumilast treatment in underweight patients (Global Initiative for Chronic Obstructive Lung Disease, 2018). Roflumilast should also be used with caution in patients with depression.

Role of Interdisciplinary Collaboration

Managing COPD requires a team-based approach, where nurses are essential to assessing treatment efficacy and toxicity, as well as navigating patient preferences. The second part of this two-part series will provide further discussion on medication management considerations based on patients' comorbidities and inhaler delivery.

Conclusion

The prevalence of COPD is only going to increase with time, and treatment complexity will continue to be a challenge due to additional choices and costs. Ongoing efforts are needed to address challenges that exist for patients, families, and the clinical team.

References

Medical History of Presented Case Study

Medical historyDepression, CHF, CVA, COPD, glaucoma, NSTEMI (2012), CAD, HTN, TIA
AllergiesNo known drug allergy
Medications

Fluticasone 115 mcg/salmeterol 21 mcg (Advair® HFA inhaler): 2 puffs po BID

Albuterol HFA: 2 puffs po Q4H PRN SOB

Albuterol-ipratropium 0.5 to 2.5/3 mL: 3 mL via nebulizer four times daily

Amlodipine 5 mg: 2 tablets (10 mg) po QDaily

Aspirin EC 81 mg: 1 tablet po QDaily

Escitalopram 10 mg: 1 tablet po QDaily

Furosemide 40 mg: 1 tablet po QDaily

Metoprolol succinate 100 mg: 1 tablet po QDaily

Pantoprazole 40 mg: 1 tablet po QDaily

Prednisone 20 mg: 1.5 (30 mg) tablet po QDaily

Senna S: 2 tablets po QAM

Tiotropium (Spiriva®) 18 mcg inhalation capsule: Inhale contents of one capsule via 2 oral inhalations once daily

No other over-the-counter agents, home remedies, herbals, or dietary supplements reported

Previously on a statin but was discontinued for unknown reasons

VaccinesUp to date on childhood vaccines; current vaccine history unknown
Social historyRetired school teacher; widowed with two daughters; three grandchildren ranging in age from 5 to 11
Smoking historyOne pack per day for >40 years; quit at age 65. Denies illicit drug or alcohol use
Physical examinationHeight: 5′4″, weight: 143 lb; vital signs: temperature = 98.8°F, RBP: RA seated 136/72 mmHg radial pulse = 70 regular, RR = 24 unlabored, pulse oximetry = 97%
GeneralFemale appearing her age and breathing through pursed lips but not in acute distress
PulmonaryDistant breath sounds with scattered wheezes throughout, crackles bilaterally at bases; no rhonchi
CardiovascularRegular rate, no murmurs, rubs, or gallops
ExteriorNo swelling, tenderness, or erythema
NeurologicalAlert and oriented to person, place, and time
Laboratory dataa

PFTs: FEV1 = 43.6% predicted, FEV1/FVC = 48.8% predicted post bronchodilator

Post-bronchodilator spirometry reveals a 6% improvement in FEV1

CrCl = 29.2 mL/min (IBW)

Gold Classification

GOLD 1MildFEV1 ≥ 80% predicted
GOLD 2Moderate50% ≤ FEV1 < 79% predicted
GOLD 3Severe30% ≤ FEV1 < 49% predicted
GOLD 4Very severeFEV1 < 30% predicted
Authors

Dr. Brandt is Professor, Geriatric Pharmacotherapy, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, and Executive Director, Peter Lamy Center on Drug Therapy and Aging; and Dr. Cook is PGY1 Pharmacy Resident, Medstar Union Memorial Hospital, Baltimore, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP, Professor, Geriatric Pharmacotherapy, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, and Executive Director, Peter Lamy Center on Drug Therapy and Aging, 20 North Pine Street, Baltimore, MD 21201; e-mail: nbrandt@rx.umaryland.edu.

10.3928/00989134-20180614-04

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