Preface: Pulmonary Disease in the Aging Patient xi
Sidney S. Braman and Gwen S. Skloot
The Effects of Aging on Lung Structure and Function 447
Gwen S. Skloot
Growth of the segment of the population older than 65 years has led to intensified interest in understanding the biology of aging. This article is focused on age-related alterations in lung structure that produce predictable changes in physiologic function, both at rest and during exercise. Increased insight into the physiology of the healthy aging lung should ultimately lead to improved methods of lung function assessment in the elderly (defined as those older than 65 years) as well as better understanding of the manifestations and possibly even the treatment of geriatric lung disease.
Inflammaging and the Lung 459
Elizabeth J. Kovacs, Devin M. Boe, Lisbeth A. Boule, and Brenda J. Curtis
With the coming of the “silver tsunami,” expanding the knowledge about how various intrinsic and extrinsic factors affect the immune system in the elderly is timely and of immediate clinical need. The global population is increasing in age. By 2030, more than 20% of the population of the United States will be older than 65. This article focuses on how advanced age alters the immune systems and how this, in turn, modulates the ability of the aging lung to deal with infectious challenges from the outside world and from within the host.
Lung Diseases of the Elderly: Cellular Mechanisms 473
Kori Ascher, Sharon J. Elliot, Gustavo A. Rubio, and Marilyn K. Glassberg
Natural lung aging is characterized by molecular and cellular changes in multiple lung cell populations. These changes include shorter telomeres, increased expression of cellular senescence markers, increased DNA damage, oxidative stress, apoptosis, and stem cell exhaustion. Aging, combined with the loss of protective repair processes, correlates with the development and incidence of chronic respiratory diseases, including idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease. Ultimately, it is the interplay of age-related changes in biology and the subsequent responses to environmental exposures that largely define the physiology and clinical course of the aging lung.
Epidemiology of Lung Disease in Older Persons 491
Carlos A. Vaz Fragoso
Older persons frequently report respiratory risk factors and symptoms and have a high prevalence of symptomatic lung disease, most commonly obstructive airway disease, interstitial lung disease, and lung cancer. Notably, coexisting nonrespiratory risk factors are also prevalent and may misidentify or modify respiratory diagnoses and their clinical course.
Evaluation of Dyspnea in the Elderly 503
Donald A. Mahler
Dyspnea is due to an imbalance between the demand to breathe and the ability to breathe. The prevalence is ∼30% for those 65 years or older with walking on a level surface or up an incline. Dyspnea is a strong predictor of mortality in elderly individuals. Anemia, cardiovascular disease, deconditioning, psychological disorders, and respiratory diseases are common causes of dyspnea. Initial treatments to relieve breathing discomfort should be directed toward improving the pathophysiology of the underlying disease. Simple and inexpensive strategies to relieve dyspnea are available. This article provides an update on the evaluation of chronic dyspnea in elderly individuals.
Asthma in the Elderly 523
Sidney S. Braman
The older population has seen the greatest increase in the prevalence of current asthma in recent years. Asthma may begin at any age and when it occurs at an advanced as opposed to a young age, it is often nonatopic, severe, and unremitting. Unfortunately, geriatric-specific guidelines are not available for the diagnosis and treatment of asthma. However, with objective monitoring, avoidance of asthma triggers, appropriate pharmacotherapy, and patient education, the disease can be managed successfully.
Chronic Obstructive Pulmonary Disease in Elderly Patients 539
Felipe Cortopassi, Puncho Gurung, and Victor Pinto-Plata
Chronic obstructive pulmonary disease (COPD) is prevalent in the elderly population, with high impact on quality of life, morbidity, and mortality. The diagnosis is usually made based on symptoms and spirometry values that support the presence of airflow obstruction. However, the condition is frequently underdiagnosed. COPD is associated with premature aging and several other medical conditions that can partially explain its underdiagnosis and management. There are several pharmacologic and nonpharmacologic interventions proven to be effective in ameliorating the symptoms of COPD. Appropriate drug delivery and reduction of side effects is also pivotal in the management of patients with COPD.
Pulmonary Vascular Diseases in the Elderly 553
Pulmonary hypertension is a pathologic hemodynamic condition defined by a mean pulmonary arterial pressure of 25 mm Hg or greater at rest. Because of age-associated stiffening of the heart and the pulmonary vasculature and the higher prevalence in the elderly of comorbidities associated with the development of pulmonary hypertension, it is an increasingly common finding in this patient population. A right heart catheterization is necessary for the diagnosis and characterization of pulmonary hypertension. The general management is to treat the underlying conditions responsible for the development of the disorder. Pulmonary vasodilators are indicated in patients with pulmonary arterial hypertension.
Lung Cancer in the Older Patient 563
Julie A. Barta, Ralph G. Zinner, and Michael Unger
Cancers of the lung and bronchus are the leading cause of cancer deaths in men and women in the United States, and two-thirds of new lung cancer cases are diagnosed in patients older than 65. There are few dedicated clinical trials in the elderly, leading to both undertreatment and overtreatment biases. Even fit older adults experience age-related decline in physiologic reserve, and additional issues of polypharmacy, geriatric syndromes, and inadequate social support are not uncommon, leading to disparities in treatment and survival. This review discusses the challenges in balancing benefits and harms in management of lung cancer in elderly patients.
Sleep in the Elderly: Unanswered Questions 579
Steven H. Feinsilver and Adam B. Hernandez
Sleep normally changes with aging, with implications for healthy elderly individuals as well as for those with disease states. Less slow wave sleep (deep sleep) is expected, along with more awakenings, and a tendency toward earlier sleep times. Rapid eye movement sleep behavior disorder is seen primarily in elderly individuals, and it often represents the earliest sign of a chronic and progressive neurologic disease. Complaints of difficulty initiating and maintaining sleep (insomnia) become more common with aging. Irregular breathing with sleep also becomes more common, with an increased Apnea Hypopnea Index that may not always be clinically important.
Comorbidities of Lung Disease in the Elderly 597
Comorbidities are common in elderly individuals with chronic respiratory diseases. They can affect disease manifestations and severity and can even impact management. Comorbidities can affect the treatment of the lung disease, particularly because of the interaction with the respiratory drugs. Thus, a multidimensional approach with multidisciplinary intervention is suggested for elderly respiratory patients, switching from a disease-oriented scheme to a dysfunction-oriented approach. Unfortunately, older individuals are often excluded from clinical trials because of advanced age and comorbidities. This article reviews the role of comorbidities in the management of respiratory diseases in the elderly.