What is the best treatment plan for an older adult with emphysema, likely with a history of smoking or exposure to harmful substances, and possibly with comorbidities such as Chronic Obstructive Pulmonary Disease (COPD) or asthma?

Management of Emphysema in Older Adults

Smoking cessation is the absolute first priority and the only intervention proven to slow disease progression and reduce mortality in emphysema, and must be addressed immediately with combination pharmacotherapy (varenicline or bupropion PLUS nicotine replacement therapy) alongside intensive behavioral counseling. 1

Immediate Priority: Smoking Cessation

• Smoking cessation is the only treatment that modifies the natural decline in lung function, and when smokers quit, their subsequent lung function decline returns to rates similar to healthy non-smokers. 1

• Abrupt cessation should be recommended rather than gradual reduction, as gradual withdrawal rarely achieves complete cessation. 1

• The decline in FEV1 in COPD patients who continue smoking is approximately 70 ml per year, with smoking dominating all other etiological factors. 2

Pharmacologic Bronchodilator Therapy

• Initiate inhaled bronchodilator therapy immediately to reduce symptoms, prevent exacerbations, and improve exercise tolerance, starting with either a long-acting β2-agonist (LABA) or long-acting anticholinergic (LAMA like tiotropium). 1

• In elderly patients specifically, anticholinergic treatment should be strongly considered as the response to β-agonists declines more rapidly than the response to anticholinergics with advancing age. 2

• For patients requiring nebulizer therapy, consider ipratropium bromide 250-500 mcg four times daily, or a combination of nebulized β-agonist with ipratropium bromide. 2

• Common pitfall: High-dose β-agonist treatment should be used with caution in elderly patients with known ischemic heart disease, where the first dose may require ECG monitoring. 2

• Beta-agonists are especially likely to cause tremor in the elderly, so high doses should be avoided unless necessary. 2

Critical Vaccinations to Reduce Mortality

• Administer influenza vaccine annually to reduce serious illness, death, risk of ischemic heart disease, and total exacerbations. 1

• Pneumococcal vaccination is essential: For patients with emphysema/COPD, administer either PCV20 alone OR PCV15 followed by PPSV23 at least 1 year later. 2

• Patients with COPD have 18 times the risk for community-acquired pneumonia compared to those without COPD, making vaccination particularly critical. 2

Pulmonary Rehabilitation

• Refer to pulmonary rehabilitation program to improve symptoms, quality of life, and physical and emotional participation in everyday activities, with benefits occurring regardless of disease severity. 1

• Pulmonary rehabilitation must be considered regardless of the age of the patient. 3

Assessment for Severe Disease Requiring Life-Prolonging Interventions

• Evaluate for hypoxemia and severe airflow limitation by checking arterial blood gas or pulse oximetry at rest, and performing spirometry to assess severity. 1

• Long-term oxygen therapy is the only treatment besides smoking cessation known to improve prognosis in patients with severe COPD and hypoxemia, with a target oxygen saturation of 88-92% if respiratory acidosis develops. 1, 4

• Hypoxemia can lead to pulmonary hypertension and cor pulmonale, which implies poor prognosis. 2, 4

Screen and Manage Cardiovascular Comorbidities

• Assess aggressively for cardiovascular disease, as approximately 26% of deaths in moderate to severe COPD are cardiovascular, and COPD and CVD share common pathobiological pathways. 1, 4

• Address cardiovascular risk factors aggressively, as they contribute significantly to morbidity and mortality. 4

Special Considerations for Elderly Patients with Inhaler Devices

• A relatively high proportion of elderly patients cannot use metered dose inhalers satisfactorily due to impaired cognitive function, memory loss, weak fingers, or poor coordination. 2

• Alternative devices should be assessed: metered dose inhaler with spacer and tight-fitting face mask, breath-activated inhaler, dry powder inhaler, or nebulizer. 2

• When using high doses of anticholinergics in elderly patients, treatment by mouthpiece rather than face mask should be considered to avoid the risk of acute glaucoma or blurred vision, as prostatism and glaucoma are more common in the elderly. 2

Monitoring and Follow-Up

• Schedule close follow-up within 2-4 weeks to assess smoking cessation progress and symptom response. 1

• Perform spirometry regularly to monitor disease progression, and reassess inhaler technique at each visit. 1

• Regular review at a respiratory clinic is recommended for patients on nebulized bronchodilator treatment. 2

• Elderly patients who do not have cognitive impairment can keep peak flow records just as well as younger patients and these should be used to monitor response. 2