Geriatric Emergency Medicine by Unknown

Author:Unknown
Language: eng
Format: epub
Publisher: Cambridge University Press
Published: 2013-12-04T16:00:00+00:00

Asthma/COPD

Chronic obstructive pulmonary disease, asthma, and CHF make up the three most common causes of intermittent dyspnea in older adults. Similarities in the ED treatment of COPD and asthma make this distinction less important than ruling out CHF.

Asthma is a disease of narrowed airways due to muscular constriction and inflammation, with 4–8% of elderly patients affected. One report showed that older patients with asthma were twice as likely as young adults with asthma to be hospitalized during one year of follow-up (14 versus 7%) [8]. A previous history of asthma will usually be present in those patients presenting with an asthma exacerbation. Although a new diagnosis of asthma in elderly patients is always looked at skeptically, the onset of new cases is reported relatively equally over all decades of life. Also suggestive of asthma is the presence of atopic symptoms like seasonal allergies and intermittent or chronic urticaria. These symptoms are often found in younger asthmatics and are part of the syndrome that causes increased response to bronchial stimulation due to higher levels of immunoglobulin E (IgE). The prevalence of this hyperreactivity decreases with age. The vast majority of older asthmatics, however, will have at least one positive allergen test to a common outdoor allergen. If asthma triggers can be identified and avoided, this may represent the simplest way to avoid emergency department visits.

Chronic obstructive pulmonary disease is a disease of airflow obstruction and loss of gas exchange surface. It is a progressive disorder that is punctuated in its later stages with acute exacerbations, and has a disproportionate impact on older patients. Physiologic changes in the aging lung cause many of the same pulmonary function test changes that are found in COPD. This fact, as well as a general trend of underreporting, makes an estimate of the prevalence of COPD in the elderly population difficult. The incidence of a new diagnosis after age 55 has been estimated at about 1% per year and the overall prevalence in the geriatric population may be as high as 11%. About 75% of exacerbations are caused by viral or bacterial infections while the rest are attributed to environmental exposure or do not have an identifiable cause.

The typical presentation of asthma and COPD, with intermittent chest tightness, shortness of breath, wheezing, cough, and increased sputum, is no different in older persons than in younger persons. Tachypnea, a variable decrease in pulmonary function, constitutional symptoms, and an unchanged chest radiograph are typical of acute exacerbations. The problem is that older individuals are more likely to have a poor perception of dyspnea related to airway obstruction. Elder patients may have moderate to severe airway obstruction yet may not complain of dyspnea. Older patients have often been found to have a limited understanding of their COPD or asthma, undertake less self-care, and are less likely to recognize symptoms of exacerbation prior to hospitalization. Because of this, it is more likely that older patients will present later and have more severe exacerbations of their disease.

On presentation, a good history and physical may confirm the diagnosis, assess the severity, and identify possible triggers.

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