Respiratory and GI Issues in Older Adults Flashcards
What can be said about COPD and age?
prevalence of COPD increases with age
What are the symptoms of COPD in older adults?
similar symptoms as younger individuals
-dyspnea
-chronic cough
-increased sputum
How is COPD diagnosed?
spirometry
-FEVC/FVC < 0.7
What are the goals of therapy for COPD in older adults?
improve exercise capacity and ability to perform daily activities
reduce symptoms
reduce exacerbations
What are the cornerstones of COPD treatment?
encourage/support smoking cessation (best intervention)
Influenza vaccine annually
COVID vaccines per current guidelines
pneumococcal vaccine x 1
pulmonary rehabilitation
long-term oxygen therapy for severe resting chronic hypoxemia
How is severity of COPD classified?
FEV1
What is COPD treatment based on?
exacerbation history, symptoms, and future risk
Differentiate the different severities of COPD based on FEV1.
GOLD 1 (mild): FEV1 > 80% predicted
GOLD 2 (moderate): 50% < FEV1 < 80% predicted
GOLD 3 (severe): 30% < FEV1 < 50% predicted
GOLD 4 (very severe): FEV1 < 30% predicted
Differentiate the different severities of COPD based on MRC.
MRC 1: at risk
-breathless with strenuous exercise
MRC 2: mild
-SOB when hurrying on the level or walking up a slight hill
MRC 3: moderate
-walk slower on level ground than people of same age or stop for breathing when walking
MRC 4: moderate
-stop for breath after walking about 100 m or a few minutes on ground level
MRC 5: severe
-too breathless to leave house or breathless when dressing
What is central to managing COPD symptoms?
bronchodilators
Describe the use of SABA and SAMAs for COPD.
prn use
-may be sufficient in very mild disease
-combination superior to either alone
Describe the benefit of LAMA and LABAs in COPD.
improve function, reduce dyspnea and exacerbations
-LAMAs have greater effect on reducing exacerbation risk
-preferred over short-acting agents except in very mild disease
-combination therapy greater symptomatic benefit and reduction in exacerbations than either alone
What is the effect of ICS on FEV1 in COPD?
does not modify decline in FEV1 in COPD
Which comorbidity with COPD would require ICS?
asthma/COPD
What is the risk of using ICS in COPD?
ICS use increases pneumonia risk
-NNH 33/yr
-NNT (high exacerbation risk) ~4/yr
When is triple therapy used in COPD?
ICS/LABA/LAMA triple therapy better than mono or dual therapy in severe disease to reduce exacerbations and improve lung function
What is the recommendation regarding LABA + ICS combo in COPD?
not recommended
Describe the approach to COPD management.
0-1 moderate exacerbations (not leading to hospital admission):
-group A (MRC 1-2 or mMRC 0-1 or CAT < 10): a bronchodilator
-group B (MRC > 3 or mMRC >2 or CAT >10): LABA +LAMA
>2 moderate exacerbations or > 1 leading to hospitalization
-group E: LABA + LAMA (consider TT if blood eso “ 300 or mod/sev sx and high ex risk)
What are some factors to consider when adding ICS to long-acting bronchodilators in COPD?
strongly favors use:
-history of hospitalization(s) for exacerbations of COPD
- > 2 moderate exacerbations of COPD per year
-blood eosinophils > 300 cells/uL
-history of, or concomitant asthma
favors use:
-1 moderate exacerbation of COPD per year
-blood eosinophils 100-300 cells/uL
against use:
-repeated pneumonia events
-blood eosinophils < 100 cells/uL
-history of mycobacterial infection
What are some side effects of the treatments used in COPD?
inhaled beta-agonists: shaky, tachycardia
-generally well tolerated
inhaled muscarinics: dry mouth
-systemic AE unlikely
inhaled corticosteroids: thrush, hoarseness
What does inhaler technique impact?
drug delivery and effectiveness
-up to 90% of older adults use inhaled device incorrectly
What is poor inhaler technique linked with?
poor symptom control and increased exacerbations
-increased risk: older age, multiple device types, lack of education
What should be done before escalating treatment in COPD?
assess inhaler technique
Describe how to pick an inhaler in older adults.
weaker hands + stronger lungs:
-Turbuhlaer, Diskus, Ellipta, Genuair
weaker hands + weaker lungs:
-Genuiar
stronger hands + weaker lungs:
-Breezhaler, Handihaler, Genuair, MDI, Respimat
stronger hands + stronger lungs:
-any inhaler
Which LAMA and LABAs are once daily?
LAMAs: tiotropium, glycopyrronium, umeclidinium
LABAs: indacaterol, oladaterol
What is an important consideration to keep in mind if a patient is using > 1 inhaler?
try to limit to one device type
What are some comorbidities that require management in COPD?
GERD may increase risk for exacerbations
“asthma/COPD”
HF - use cardio selective beta-blockers, monitor impact on COPD symptoms
osteoporosis - more common in COPD
depression and anxiety - common and underdiagnosed
vitamin D deficiency associated with COPD exacerbations
Which medications should be avoided if possible in COPD?
non-selective beta-blockers
?ACEI - watch for cough
benzodiazepines and opioids
1st generation antihistamines, other oral anticholinergics
What are COPD exacerbations?
sustained worsening (>48h) of respiratory symptoms
Why are COPD exacerbations important?
contribute to disease progression
hospital admissions –> functional decline
increased morbidity and mortality
exacerbations become more frequent as COPD progresses
Describe pharmacotherapy management in a COPD exacerbation.
SABA scheduled q4-6 hours
- + SAMA if needed
oxygen therapy if needed
-target O2 saturation 88-92%
maintain background pharmacotherapy or escalate as needed
-should not be used in place of short-acting bronchodilators
systemic corticosteroids to improve FEV1, oxygenation, and shorten hospitalization (limit 5-7 days)
-prednisone 30-50mg daily in AM
antibiotics indicated if:
-increased sputum purulence + 1 of: dyspnea or increased sputum volume
-or need for mechanical ventilation
What constitutes a high risk individual during a COPD exacerbation?
FEV1 < 50%
CAD
chronic oral corticosteroid use
> 4 exacerbations per year
use of home O2
antibiotics used in last 3 months
Differentiate the antibiotics used for low and high risk individuals during a COPD exacerbation.
low risk:
-amoxicillin
-doxycycline
-TMP/SMX
-clarithromycin
-azithromycin
-cefuroxime
-cefprozil
high risk individuals:
-amoxiclav
-levofloxacin
-moxifloxacin
Why is there an increased prevalence of GERD and dyspepsia in older adults?
age-related changes in GI system
-LES dysfunction
-poor esophageal clearance
-hiatal hernia
-delayed gastric emptying
-increased intra-abdominal pressure
What are some potential dietary contributors to GERD?
caffeine
alcohol
tomatoes/tomato sauce, garlic, onions
spicy/fatty foods
chocolate, peppermint
What are some potential medication contributors to GERD?
NSAIDs
steroids
bisphosphonates
potassium
iron
opioids
anticholinergics
nitrates
calcium channel blockers
What are the alarm symptoms with dyspepsia or GERD?
new onset symptoms after age 50 or VBAD –> refer for endoscopy
VBAD = vomiting, bleeding, abdominal mass or wt loss, dysphagia
Which individuals require GI prophylaxis with a PPI or misoprostol?
moderate risk for GI toxicity
if high risk –> avoid NSAID (preferably) or use coxib + PPI
Differentiate the different risk categories for NSAID GI toxicity.
high risk:
-hx of complicated ulcer, especially recent
-multiple (> 2) risk factors
moderate risk (1-2 risk factors):
-NSAID use: high dose or multiple agents
-history of uncomplicated ulcer
-older age: > 60 yrs, > 70 yrs ++
-concurrent ASA including low dose, corticosteroids, anticoagulant, SSRI
-history of CVD
low risk:
-no risk factors
What is an important intervention for GERD/dyspepsia in older adults?
lifestyle measures
What can be used for mild symptoms of GERD/dyspepsia in older adults?
prn antacids may be sufficient
-avoid aluminum and magnesium-containing antacids in older adults
H2RA prn or once-twice daily scheduled
-require dosage adjustments in renal impairment to prevent anticholinergic AE
What are PPIs 1st line for?
moderate-severe GERD
erosive esophagitis
ulcer healing
What is the recommended duration of therapy for PPIs?
4-8 weeks
Which individuals require indefinite PPIs?
Barrett’s esophagus
grade 4 erosive esophagitis
previous GI bleed
What are the potential long-term adverse effects of PPIs?
pneumonia
C. difficile infection
hypomagnesemia
vitamin B12 deficiency
osteoporosis
AKI
?dementia
What should be done yearly with chronic PPIs?
try to deprescribe in the absence of compelling indications
What is the relationship between age and constipation?
prevalence of constipation increases with age
What is the cause of constipation in older age?
medical conditions
medications
pelvic floor dysfunction
slowed intestinal transit
What is constipation?
unsatisfactory defecation due to infrequent stools and/or difficult or incomplete evacuation
-subjective
-straining or hard stools most common symptoms
What are the alarm features for constipation?
age over 50 with recent onset of symptoms
rectal bleeding or rectal prolapse
fever
significant weight loss
nocturnal symptoms
abnormal laboratory blood work (e.g. anemia or iron deficiency)
strong family history (bowel cancer, IBD, celiac)
palpable abdominal or rectal mass
presence of alarm features –> physician consult to rule out an underlying condition
What are some medication causes of constipation?
anticholinergics
iron
opioids
calcium
CCBs (verapamil > diltiazem > CCB)
What is first line for constipation whenever feasible?
lifestyle recommendations
What are the lifestyle recommendations for constipation?
physical activity as tolerated
adequate fluid intake
-apple, pear, prune juice
-particularly important with bulk-forming laxatives
-also helpful if using osmotic laxatives
dietary fibre
-soluble preferred over insoluble due to better tolerability
What is the evidence for osmotic laxatives in older adults?
RCT data supports use of osmotic laxatives in older adults
-PEG 3350 17g daily
-lactulose 15-30 ml daily-TID
-glycerin suppositories (prn)
What is the MOA of osmotic laxatives?
combined osmotic and local irritant effect stimulates colonic peristalsis
What is the onset of osmotic laxatives?
24-96 h (usual oral dosing)
15-30 mins with glycerin suppositories or PEG bowel prep
What is the MOA of bulk-forming agents?
dissolves or swells in intestinal fluid and forms a gel which facilitates stool passage
-not absorbed systemically
What is required for bulk-forming agents to work?
sufficient fluid consumption (~250 ml)
What are the adverse effects of bulk-forming agents?
gas and cramping
potential for obstruction
What is the MOA of stool softeners?
anionic surfactant, facilitates wetting and passage of fecal material
-docusate
What is the role of docusate in constipation?
limited value in management of constipation
may be useful in situations where straining is to be avoided
-ex: hemorrhoids, post-anorectal surgery
What are the adverse effects of docusate?
generally well-tolerated
can contribute to abdominal pain and cramps in higher doses
What are examples of saline laxatives?
magnesium citrate/hydroxide/sulfate
sodium bisphosphate
What is the MOA of saline laxatives?
non-absorbable cations and anions draw fluid into intestines –> increase intestinal motility
What is the onset of saline laxatives?
0.5-3 h (oral)
2-5 mins (rectal)
What is the use of saline laxatives?
when acute bowel evacuation is required
-should not be used for chronic constipation management due to potential for elyte losses and deficiencies
What are the adverse effects of saline laxatives?
overdose or chronic use can lead to hypermagnesemia, hyperphosphatemia, abdominal cramping, NV, or edema
What is the strongest stimulant laxative?
bisacodyl stronger than senna
What is the MOA of stimulant laxatives?
propulsive peristalsis, may stimulate secretion of water and electrolytes
What is the onset of stimulant laxatives?
6-12 hours
What is the indication for stimulant laxatives?
chronic medication-induced constipation
What are the adverse effects of stimulant laxatives?
cramping and abdominal pain, urine discolouration
?potential for long-term bowel dysfunction or pigmentation
NV if EC compromised
