Exacerbations of chronic obstructive pulmonary disease (COPD) in the elderly and in the post-acute and long-term care populations “tend to present very atypically,” with symptoms such as dizziness, weakness, chest pain, and confusion, Milta Little, DO, CMD, said at the Annual Conference of AMDA — the Society for Post-Acute and Long-Term Care Medicine. “We need to help our staff understand this,” she said. “We need to make sure that changes are identified and exacerbations are brought to our attention so that we can institute therapy early and prevent decline and hospitalization.” COPD is prevalent in nursing homes, yet there are high rates of exacerbation and high rates of undermedication. In a retrospective analysis of more than 126,000 nursing home residents published 5 years ago, 17% of residents with COPD received no respiratory medication, 60% were not prescribed long-acting bronchodilators or inhaled corticosteroids, and 20% had two or more exacerbations in 1 year (J Manag Care Pharm 2012;18:598–606). “We need to follow the GOLD [Global Initiative for Chronic Obstructive Lung Disease] guidelines for management of COPD,” she urged. The guidelines form the basis of other published COPD guidelines, including the Society’s clinical practice guideline on managing this progressive lung disorder in the post-acute and long-term care setting. The Society recently came out with a pocket version of its COPD guidelines. “We don’t have much data from the long-term care setting, but the data that exist suggest that people generally receive the same benefits [from management per the GOLD guidelines] in those settings and age groups as do younger community-dwelling populations,” she said. Per the GOLD guidelines, regardless of COPD stage, “you want to start with non-pharmacologic interventions” — mainly smoking cessation, exercise, and a “good vaccination protocol,” she said, noting that quality of life and relief from dyspnea are management goals that are just as important as reduced mortality and hospitalization. The optimization of drug therapies is at the heart of management, however. On this front, Dr. Little stressed two key points. First, age-related changes in lung function can limit older residents’ responsiveness to drugs. Second, age can also increase their susceptibility to adverse drug reactions. “Doubling the dose [of a drug] in an older person is not the answer [to decreased responsiveness] because that person is also at higher risk of adverse drug events,” she said. “Combination therapy is better.” For GOLD stages II–IV (moderate to very severe), and particularly in advanced stages, “combining the long-acting muscarinic antagonists [LAMAs] and long-acting beta-agonists (LABAs) can help improve lung function,” she said. LAMAs, or anticholinergics, are the first-line therapy for GOLD stages II–IV. She pointed out that systematic reviews and meta-analyses published in the last 5 to 10 years have shown that, within the main classes of drugs, medications have similar efficacy and safety. Among Dr. Little’s other clinical pearls on pharmacologic management: •Dry powder inhalers require a relatively high force of inspiration to deliver enough drug to the lungs and ward off the risk of systemic side effects, but “interestingly, people with mild to moderate cognitive impairment in long-term care can be educated to use these devices properly.”•Nebulizers are more staff-intensive to use but only require normal tidal respiration and are “really good for those patients who have a lot of functional or cognitive impairment.”•Spacers are sometimes used with metered dose inhalers, but “there is some evidence that even applying the spacer in our older adult population doesn’t really help to deliver the drug any better.”•Inhaled corticosteroids (ICS) should be reserved for more advanced illness and frequent exacerbations. (Short-acting bronchodilators are the mainstay treatment for acute COPD exacerbations.) However, there is evidence that starting an ICS/long-acting beta-agonist combination early on in older patients who have an asthma component to their COPD (asthma–COPD overlap syndrome) decreases death and hospitalization. To identify an asthma component, “look for some reversibility on spirometry and an eosinophilic rather than a neutrophilic type of patient.”•Regarding bronchodilators, “the literature suggests that you have fewer side effects with long-acting beta-agonists than with the short-acting. That’s one reason why you want to move them to the long-acting if they have GOLD stage II or above.” Research is showing, Dr. Little said, that continuous oxygen therapy is better than nocturnal-only for residents with hypoxia at night. “They may be having symptoms during the day that we’re not catching,” she said. “So we may want to encourage … our residents to wear that oxygen continuously.” Christine Kilgore is a freelance writer in Falls Church, VA.