Discuss the management of COPD with reference to recent recommendations

COPD is characterised by airflow obstruction that is not fully reversible, shows little variability over time, is usually progressive, and reflects small-airway disease and emphysema. Diagnosis requires a post-bronchodilator FEV /FVC < 0.70 (or below the lower limit of normal, which is preferred in the elderly).

COPD is the fifth largest cause of disability worldwide; worldwide prevalence is 4–10%, but 12–15% in the elderly. Despite this, it is persistently under- and mis-diagnosed in older adults, largely because breathlessness is attributed to age, obesity or cardiac disease.

Severity of airflow obstruction (post-bronchodilator FEV /FVC < 0.7): Stage 1 mild, FEV ‡ 80%; Stage 2 moderate, 1 1 50–79%; Stage 3 severe, 30–49%; Stage 4 very severe, < 30% predicted.

Assessment must be multidimensional, not spirometric alone: breathlessness (mMRC), health status (CAT), exercise tolerance (shuttle walk or six-minute walk test), BMI, oxygen saturation if FEV < 50% or signs of cor 1 pulmonale, screening for anxiety and depression (HADS), and the exacerbation rate.

Comorbidity is the rule in the older COPD patient and is classified as: co-causal (shared smoking risk — ischaemic heart disease, heart failure, lung and bladder cancer, CKD, aortic aneurysm); coexisting (diabetes, hypertension, benign prostatic hypertrophy, glaucoma, OSA); and complicating (anxiety/depression, osteoporosis, sarcopenia, arrhythmias, dysphagia, pulmonary embolism).

A critical geriatric prescribing trap: sarcopenia blunts the rise in serum creatinine, so moderate (GFR 30–60) and even severe renal impairment go unrecognised, leading to overdose of renally cleared drugs during exacerbations. Umeclidinium and aclidinium are safe in renal failure as they are hepatically metabolised to inactive derivatives.

Smoking cessation is the only intervention that slows the age-related decline in FEV . Use nicotine 1 replacement, bupropion or varenicline; quit rates in older adults are as good as or better than in the young. E-cigarettes are not recommended as a cessation aid.

Vaccination: annual influenza and pneumococcal vaccination for all; current guidance adds RSV vaccination and COVID-19 vaccination, and pertussis-containing Tdap.

Pulmonary rehabilitation improves dyspnoea, health status and exercise tolerance, and secondarily mood and quality of life; it should be part of integrated management from the early stages, not reserved for end-stage disease.

Self-management plans covering recognition and early treatment of exacerbations are vital; as disease progresses, there must be an opportunity for advance care planning and discussion of end-of-life wishes.

On-demand short-acting bronchodilators alone should be discouraged in the elderly because they lead to adverse drug reactions and overdosing; regular long-acting therapy is preferred.

LAMA and LABA are the foundation: both improve symptoms, health status and exacerbation rate, and LAMAs are clearly superior to short-acting ipratropium. Escalate to LABA + LAMA for persistent breathlessness.

Inhaled corticosteroids are added for frequent exacerbators or those with asthma-like features. They increase the risk of non-fatal pneumonia, but this does not outweigh benefit in appropriately selected patients. Blood eosinophil count guides the decision — ICS considered above 300 cells/µL, avoided below 100 cells/µL.

Second-line options: slow-release theophylline at low dose (poor therapeutic index, drug interactions with macrolides and quinolones); roflumilast (PDE-4 inhibitor) for frequent exacerbators with chronic bronchitis and FEV 1 < 50% — monitor for weight loss, diarrhoea and mood disturbance, with limited safety data in the elderly; high-dose acetylcysteine as a mucolytic/antioxidant; nebulised bronchodilators where inhaler technique cannot be corrected.

Maintenance oral corticosteroids should generally be avoided — risks outweigh benefits; where repeated courses are used, screen and treat for osteoporosis, which should in any case be routine in elderly COPD.

Long-term oxygen therapy (LTOT) for ‡ 15 hours a day improves survival in severe COPD with persistent hypoxaemia. Prescribe during clinical stability, to non-smokers, when PaO < 7.3 kPa, or PaO 7.3–8.0 kPa with 2 2 secondary polycythaemia, pulmonary hypertension, peripheral oedema or nocturnal hypoxaemia. Screen by referring patients with saturation < 93%, or < 95% with possible cor pulmonale.

Exacerbation management: increased bronchodilators; oral corticosteroids reduce length of stay and treatment failure; antibiotics where sputum is purulent (commonest organisms Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis) — but antibiotics should be withheld if there is no sputum purulence. Controlled oxygen targeting SpO 88–92%; NIV if pH < 7.35 despite maximal medical therapy, which 2 reduces mortality, intubation and length of stay.

Prognosis: about one-third of admitted patients are readmitted within 30 days and 15% die by three months; roughly 50% of patients on LTOT survive three years. In older adults the main predictors of mortality are disability, low BMI, lung function and use of LTOT.

Palliative care: patients judged to be in their last year of life should be placed on an end-of-life register and offered opioids and benzodiazepines for refractory breathlessness. The textbook is explicit that the move from an active to a palliative approach all too often comes too late.

Nutrition and sarcopenia: hypercatabolism and accelerated muscle loss characterise severe exacerbations. Nutritional support improves respiratory and peripheral muscle strength but not lung-function indices, and should be combined with exercise in a comprehensive programme for the frail patient.