A Review of Smoking in the Elderly

D'Arcy Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Fellow in Care of Elderly at Baycrest Centre, Toronto, ON.

Prevalence of Smoking in the Elderly
Smoking is one of the major causes of morbidity and mortality in Canada. In fact, it has been called the leading preventable cause of death in North America.¹ This is because smoking is a known risk factor for four of the leading causes of death in the industrialized world--coronary heart disease, cancer, lung disease and stroke--and because it contributes to many other causes of morbidity.² While the current prevalence of smoking in Canadians aged 15 years and older declined by 10.3% between 1985 and 1999, the numbers remain high for both men and women (26.8% and 22.9%, respectively, in 1999).³ In those aged 65 and older, current smoking prevalence decreased by 8.9% over the same time period. However, it is estimated that 11.6% of seniors continue to smoke. The prevalence of smoking is highest in the Atlantic provinces and Quebec, and lowest in Saskatchewan and Ontario.⁴

Impact of Smoking on Health of the Elderly

Mortality
The health-related impact of smoking in the elderly is manifold. The increase in mortality has already been mentioned.

The Billowing Impact of Cigarette Smoking

In the past year, the head of Cancer Care Ontario died, tragically of cigarette-induced lung cancer. I learned last week that a gifted and brilliant surgeon has been diagnosed with unresectable cigarette-induced lung cancer. He is a thoracic surgeon with an international reputation in the surgical management of lung cancer. When one knows the people involved, the lunacy of cigarette addiction becomes even more disturbing. A report this week that early cigarette smoking among teenage girls (the current growth market) doubles their risk of breast cancer reinforces my long-standing desire to grab cigarettes from children and destroy them (I have controlled these desires, and thus I am still free to walk the streets).

Older people also suffer from the pernicious effects of tobacco. They are part of a cohort that started smoking when society considered cigarettes an acceptable part of life, and their longer period of smoking means more complications. Many of the articles in this issue focus on the pulmonary effects of tobacco, but it must be remembered that the number of premature cardiac deaths attributed to tobacco is even greater than the number of pulmonary deaths.

Dr. D'Arcy Little, Medical Director of CME for Geriatrics & Aging, sets the stage for this issue with his article on tobacco use in the elderly. Drs. Michael Johnston and Yaron Shargall discuss current practices in the screening and treatment of lung cancer, while Dr. Robert Hyland reviews chronic obstructive lung disease and its management. Drs. John Granton and Moiz Zafar cover the issue of pulmonary hypertension, an entity for which new information and new treatments seem to hit the general medical journals every month. Smoking is, of course, an important factor in the pathogenesis of secondary pulmonary hypertension via its contribution to chronic lung disease. The article on the aging respiratory system by Drs. Don Sin and Benjamin Chiam helps us put the various diseases discussed in this month's issue into the proper context. We have even included a patient information section detailing The BreathWorks Program, courtesy of the Ontario Lung Association. We are grateful for their participation.

As well as our focus on lung diseases in the elderly, we have our usual collection of interesting topics. Dr. Gladstone continues his superb series on the neurological examination in aging, dementia and cerebrovascular disease with an article on cerebellar testing. This is particularly relevant as instability and falls are considered "geriatric giants". Dr. Fodor discusses hypertension in the elderly, and Dr. D'Arcy Little explores an unusual aspect of dementia, that of personhood and spirituality.

Enjoy this edition, and remember, don't smoke!

Reducing Lung Volume--is it worth the risk

A recent paper suggests that lung-volume--reduction surgery, believed to be a potentially valuable treatment for advanced emphysema, may be dangerous for some patients. The operation involves the resection of 20-35% of the emphysematous lung, by means of either a median sternotomy or video-assisted thorascopy. Generally, lung function, exercise capacity and quality of life improve after surgery, but results have been shown to vary.

The National Emphysema Treatment Trial is a randomized, multicentre trial comparing lung-volume--reduction surgery with medical treatment. The study found that, for patients with emphysema who have a low forced expiratory volume in one second (FEV1) and either a homogeneous emphysema or a very low carbon dioxide diffusing capacity, the 30-day mortality rate after surgery was 16%. This mortality rate was in comparison to a rate of 0% among 70 medically treated patients.

The main goal of the trial is to compare survival rates and exercise capacity two years after lung-volume--reduction surgery with the results obtained after medical treatment. Another important goal of the trial is to identify selection criteria for the surgery. As a result of the findings of this study, the National Emphysema Treatment Trial has now modified its protocol to exclude this particular group of patients.

Source

1. National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung-volume--reduction surgery. New England Journal of Medicine. From the website http://content.nejm.org/, to be published in the October 11 issue.

Chronic Obstructive Pulmonary Disease--A Review

D'Arcy Little, MD, CCFP
York Community Services,
Toronto, and
Department of Family Medicine
Sunnybrook Campus of
Sunnybrook and Women's
College Health Sciences Centre,
Toronto, Ontario

Chronic Obstructive Pulmonary Disease (COPD) is a general term for a group of conditions characterized by some or all of the following features: a chronic cough, increased sputum production, shortness of breath, airflow obstruction, and impaired gas exchange. Unlike asthma, which is usually episodic and reversible, the major characteristics of COPD are that it is chronically progressive and irreversible. Under the umbrella of COPD, there are two major disease categories: chronic bronchitis and emphysema. Chronic bronchitis is clinically characterized by a productive cough, lasting three months of the year for at least two consecutive years. Pathologically, chronic bronchitis is characterized by mucus gland and airway smooth muscle hypertrophy. Emphysema is clinically characterized by dyspnea, although the other features mentioned above may also be present in various degrees. Technically, emphysema is a pathological diagnosis characterized by destruction of the air spaces distal to the terminal bronchioles (respiratory bronchioles, alveolar ducts and alveoli). It is worthwhile to note that it may not be clinically important, or useful, to categorize a patient as having either chronic bronchitis or emphysema.

Diagnostic Approaches to New Onset Respiratory Symptoms in the Elderly: Dyspnea and Cough

Lilia Malkin, BSc

The myriad of human physiological systems undergo change as the body grows older, and the respiratory system is no exception. For a more detailed look at the aging lungs, please see the Biology of Aging article, Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly. It is worth noting, however, that the evaluation of the geriatric patient presenting to the physician's office with respiratory symptoms such as cough and shortness of breath is quite similar to that of a younger adult. The following is a two-part review of diagnostic and treatment approaches to the geriatric patient presenting to the primary care physician for the first time with symptoms of dyspnea and cough, respectively.

Part I. Dyspnea
Dyspnea may be defined as "abnormal or uncomfortable breathing in the context of what is normal for a person according to his or her level of fitness and exertional threshold for breathlessness."¹ However, upon presenting to the physician, patients will usually refer to the alarming feeling of "shortness of breath," or "difficulty breathing." The complaint is fairly common, owing to the plethora of conditions that give rise to this symptom.

Bronchiectasis is Often Mistaken for Chronic Bronchitis

Nariman Malik, BSc

The word bronchiectasis is derived from the Greek words bronchos, meaning windpipe, and ektasis, which means extension or stretching.¹ Bronchiectasis is defined as the abnormal and persistent dilatation of bronchi due to destructive changes in the elastic and muscular layers of the bronchial wall.² It is a condition that can affect airways of all sizes but tends to mainly affect medium-sized airways. It can be either focal, affecting the air supply to a limited region of lung parenchyma, or diffuse in nature. Bronchiectasis most often is a consequence of chronic or recurrent infections and the associated secretions that pool in these airways.³

In North America, fewer and fewer patients present with gross disease.⁴ The advent of antibiotics has lead to a dramatic decrease in severe respiratory infections and the subsequent development of bronchiectasis. However, because its incidence has decreased in developed countries, it is now believed that low clinical suspicion is a factor in the underdiagnosis of bronchiectasis.⁵ Bronchiectasis is characterized by the production of large amounts of sputum, which is also a defining trait of chronic bronchitis. As such, patients who are producing copious amounts of sputum and who smoke are likely to be misdiagnosed with chronic bronchitis.

Theophylline Recommended as an Add-on Therapy for Chronic Lung Disease

Anna Liachenko, BSc, MSc

The popularity of theophylline, a bronchodilator used in the treatment of asthma and other bronchospastic diseases for over 60 years, has been declining due to its narrow therapeutic index and the perceived lack of anti-inflammatory effects. Instead, newer therapies, such as inhaled long-acting corticosteroids, have been increasingly recommended. Although valued for their anti-inflammatory properties, these newer therapies can nevertheless produce serious side effects at therapeutic concentrations. Fortunately, the prescribed dosages can be decreased due to the recently discovered anti-inflammatory properties of theophylline, which is now recommended as an add-on therapy to corticosteroids. In this article, the beneficial effects and necessary precautions when using theophylline are examined, with particular emphasis on the elderly.

In Canada, theophylline is currently indicated for the symptomatic treatment of reversible bronchospasm associated with asthma, chronic bronchitis, emphysema, and associated bronchospastic disorders. Historically, asthma was treated mainly with bronchodilators. During the 1980s it became apparent that an unacceptably high rate of asthma-related hospitalizations and asthma deaths were partly attributed to the under-use of anti-inflammatory medications. For this reason, the use of inhaled corticosteroids increased. Unfortunately, there is some systemic absorption of inhaled corticosteroids.

Age-related Changes to the Respiratory System Will Not Affect Healthy Elderly

Rhonda Witte, BSc

"I'm so out of breath! I must be getting old." Have you ever heard someone use that expression before? Chances are that you have. You may have even used it yourself. Sometimes it is used as an excuse for not having exercised enough. But is there truth to that statement? The answer is yes. With age, the respiratory system changes and may predispose us to shortness of breath in situations where we may not have been before.

Exogenous and endogenous factors play a role in age-associated changes to the respiratory system. Infection, climate, air pollution and mechanical injuries are a few of the exogenous insults the lungs incur over time.¹ System diseases and infectious diseases are endogenous factors that can often affect the lungs in elderly patients.¹ For example, COPD occurs more commonly in the elderly. Esophageal disorders and Parkinson's disease are other endogenous factors which are frequently associated with lung aspiration and pneumonia in elderly individuals.¹

Older and younger patients differ with respect to pulmonary function because of age-related changes of the respiratory system. Consequently, it is important that the physician in care is aware of the changes so that proper care is administered. Although much more work needs to be done to determine the exact consequences of these age-related changes, one should be aware of possible complications that may occur.