Geriatric MedicineTier 1Disease (DEADMAN)

Respiratory conditions - chronic obstructive pulmonary disease

Description

Progressive airflow limitation, poorly reversible - emphysema + chronic bronchitis phenotypes overlap
In geriatric medicine, key issues are diagnostic overlap with HF/deconditioning, symptom burden management, and end-of-life planning rather than pathophysiology detail

Prevalence rises with age; underdiagnosed in older adults (symptoms attributed to "ageing"/deconditioning)
Major cause of hospital readmission and frailty progression in >70s

Smoking dominant cause; also biomass fuel exposure, occupational, alpha-1-antitrypsin deficiency (consider if early-onset/non-smoker/basal emphysema)
Inflammatory airway remodelling + alveolar destruction -> irreversible airflow obstruction, air trapping
Ageing itself reduces elastic recoil and respiratory muscle strength - compounds true COPD physiology

Spirometry - post-bronchodilator FEV1/FVC <0.7 confirms; may be technically difficult in frail/cognitively impaired - use clinical judgement
Distinguish from HFpEF, deconditioning, anaemia, ILD - overlapping breathlessness in this population; consider combined cardiopulmonary contribution
Assess exacerbation frequency/severity - drives step-up therapy
Screen for anxiety/depression (common, amplifies dyspnoea perception)
Nutritional status - cachexia in advanced disease

By symptom burden and exacerbation risk (GOLD-style ABE grouping)

Bronchodilators - LAMA/LABA combination for most symptomatic patients
Inhaled corticosteroid added only if frequent exacerbations + eosinophilia - not routine, inc pneumonia risk in elderly
Ensure inhaler technique and device suitability - dexterity, cognition, inspiratory flow determine device choice (consider spacer, nebuliser if severe cognitive/physical limitation)

Non-pharmacological (often higher yield in frail elderly)

Pulmonary rehabilitation - improves function, reduces readmission, benefit regardless of age
Smoking cessation at any age
Vaccination - influenza annual, pneumococcal, COVID, pertussis-containing booster
Home oxygen if criteria met (resting hypoxaemia) - assess fall/trip hazard from equipment
Nutrition support - cachexia management

Exacerbations

Prednisolone short course, antibiotics if purulent sputum/increased volume
Avoid unnecessary long-term oral corticosteroids - osteoporosis, falls, delirium risk

Advanced disease

Symptom-directed opioids for refractory dyspnoea (low dose, monitor)
Advance care planning - COPD trajectory is punctuated decline; discuss ceilings of care before crisis admission

IHD, HF (shared risk factor - smoking)
Osteoporosis (smoking, steroids, deconditioning)
Depression/anxiety
Sarcopenia, cachexia, frailty
Lung cancer - shared risk factor, maintain suspicion for new symptoms/weight loss

Progressive decline punctuated by exacerbations, each with incomplete recovery
Exacerbation frequency predicts mortality and hospitalisation trajectory
Death often from cardiovascular event, infection, or respiratory failure
Frequent overlap and misattribution with general frailty in advanced age - reassess reversible contributors before assuming pure disease progression

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