Elderly Chronic Obstructive Pulmonary Disease Patients Research Articles

Age does not hamper the response to pulmonary rehabilitation of COPD patients

pulmonary rehabilitation (PR) improves health status and exercise tolerance, but not respiratory function in patients with chronic obstructive pulmonary disease (COPD). Our objective was to identify predictors of improvement in the 6-min walked distance (6'WD) in elderly COPD patients after PR. this was a prospective observational study performed in an ambulatory rehabilitation setting. We enrolled 74 patients aged 65-83 years (mean: 74.2, SD: 4.4) with stable COPD in GOLD stage 3-4. About half (45.6%) of them had a basal O(2) saturation of 90% or less. After a baseline multi-dimensional assessment, patients underwent a 20-session rehabilitation cycle including training of the upper and lower extremities, and respiratory exercises, along with education sessions. The difference between final and basal 6'WD was expressed as a per cent of the basal value (6'WD gain). Patients were divided into two groups according to whether the 6'WD gain was above or under the 75th percentile, corresponding to 33% gain. patients whose 6'WD improved more had lower baseline forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) (46.0 versus 52.2%, P = 0.03) and baseline 6'WD, both as an absolute value (329.5 versus 408.9 m, P = 0.01) and as a per cent of the predicted (71.1 versus 93.5%, P = 0.002). After correction for potential confounders, baseline 6'WD was the only variable associated with the outcome (OR for 5% increments: 0.79; 95% CI 0.65-0.95). among elderly patients with COPD, a comprehensive rehabilitation programme can significantly improve the 6'WD even in the presence of chronic hypoxemia. The most physically impaired patients achieve the greatest benefit from rehabilitation, but we could not develop a model accurately predicting the response to rehabilitation.

Efficacy and safety of formoterol fumarate delivered by nebulization to COPD patients

Nebulized solutions of long-acting bronchodilators provide an alternative to DPI and MDI delivery, particularly for COPD patients unable to use hand-held devices easily or correctly. The long-acting beta2-agonist, formoterol fumarate, is differentiated by its onset of significant bronchodilation within 5 min of administration. In a randomized, double-blind, double-dummy trial, COPD subjects (n=351, mean forced expiratory volume FEV1=1.3 L, 44% predicted) received nebulized formoterol fumarate (Perforomist inhalation solution; FFIS 20 microg) or DPI (Foradil Aerolizer; FA 12 microg), or placebo twice daily for 12 weeks. Efficacy was assessed with 12-h pulmonary function tests, and quality of life was assessed before and after treatment with the St. George's Respiratory Questionnaire (SGRQ). At the 12-week endpoint, FFIS significantly increased FEV1 AUC0-12h relative to placebo (p<0.0001). No evidence of tachyphylaxis was observed as indicated by maintained FEV1 AUC and reduced rescue albuterol use throughout treatment. FFIS also significantly increased peak FEV1, trough FEV1, and standardized FVC AUC0-12h compared with placebo. SGRQ assessment at Week 12 demonstrated significant and clinically meaningful improvements in total score (FFIS vs placebo, -4.9, p=0.0067), symptom, and impact scores. No significant differences in efficacy were observed between the two active treatments. Drug related AEs in the FFIS arm with a frequency > or = 1% and exceeding placebo were dry mouth, nausea, and insomnia. Nebulized FFIS provided significant improvement in respiratory status and quality of life in subjects with COPD relative to placebo and was well tolerated. The efficacy and safety profile of FFIS was comparable to FA DPI.

Inspiratory flow rates at different levels of resistance in elderly COPD patients

Dry powder inhalers (DPIs) are increasingly replacing metered dose inhalers in elderly chronic obstructive pulmonary disease (COPD) patients. However, most DPIs are dependent on inspiratory flow, which is compromised by the ageing process itself. Using the in-check dial method, the present study compared peak inspiratory flow (PIF) rates in 26 elderly COPD patients and 14 matched control subjects, at a pre-set resistance level of the Aeroliser, Diskus and Turbuhaler inhalers. It was found that the PIF measured by the in-check method positively correlated with the PIF derived from spirometry, forced vital capacity and maximal inspiratory pressure, while a negative, but significant, correlation was observed with age. PIF derived from spirometry and age were independent variables which determined PIF across the device, whereas the presence or absence of COPD was not related. When comparing elderly COPD patients with matched elderly controls no difference could be found in PIF at the different resistances. However, an important number of patients did not reach the recommended flow rate, especially when using the Turbuhaler (30%). In conclusion, the present study demonstrates that, in elderly patients, the ability to generate sufficient inspiratory flow across a dry powder inhaler is compromised, irrespective of the presence of chronic obstructive pulmonary disease.

Effects of annual influenza vaccination on winter mortality in elderly people with chronic pulmonary disease

Although there is a general agreement for the recommendation of the influenza vaccine to persons with chronic obstructive pulmonary disease (COPD), the magnitude of clinical effectiveness and benefit from the annual vaccination is controversial. We assessed the effects of annual influenza vaccination on winter mortality in older adults with COPD. This prospective cohort study included 1298 Spanish community-dwelling individuals aged 65 years or older with a diagnosis of COPD followed from 1 January 2002 to 30 April 2005. The primary outcome was all-cause death during influenza periods (January-April). Multivariable Cox proportional hazard models adjusted by age, sex and comorbidity were used to evaluate vaccine effectiveness. Influenza vaccination was associated with a non-statistically significant 16% reduction in winter mortality among vaccinated COPD patients [unadjusted hazard ratio (HR): 0.84; 95% confidence interval (CI): 0.60-1.17]. Multivariable analysis showed that there was an insignificant trend towards a reduced mortality in the vaccinated group considering overall influenza periods 2002-2005 (adjusted HR: 0.76; 95% CI: 0.52-1.06; p=0.098). We estimated that, in the total COPD population, one death was prevented for every 187 annual vaccinations (95% CI: 62 to infinity). Our data suggest benefit from the influenza vaccination and support an annual vaccination strategy for elderly COPD patients.

Inhaled therapy in elderly COPD patients; time for re-evaluation?

chronic obstructive pulmonary disease (COPD) prevalence steadily increases with age. However, the effectiveness of inhaled therapy in the elderly COPD population has rarely been formally evaluated. We studied a group of elderly patients with COPD with a range of severity, selected from one General Practice register to measure peak inspiratory flow (PIF) and assess patient perceived benefit. we recruited 53 randomly selected elderly patients with COPD (36 males) with a mean age of 73.5 years (range 65-89 years). The evaluation consisted of (i) information obtained from directed questions and (ii) objective measurements of the ability to generate adequate PIF for a variety of inhalers. Patients answered questions regarding ease of use, perceived benefit from and specific problems encountered with their inhaler. Three recordings of PIF were measured at varying inhaled resistances using the 'In-Check Dial'. thirty-five were classified as mild, 17 moderate and 1 severe COPD. All patients used a metered dose inhaler (pMDI), and 12 of the patients also used a dry powder inhaler (DPI). Forty six per cent of patients using a pMDI and 17% of those using a DPI rated their device difficult to use. No patient used a nebuliser. Thirty-one of the 53 patients using just a pMDI felt they were able to perceive benefit in comparison to 4 of the 12 DPI users. Even though most DPI users (10/12) had rated their inhaler as easy to use, 50% were 'unsure' as to whether they received any clinical benefit. Most patients were unable to generate sufficient inspiratory flow to use the higher resistance DPI's and patients with COPD who were able to generate adequate PIF were invariably mild. A significant negative correlation was found between age and the PIF achieved when assessed using the high resistance device setting (R = 0.84, P<0.0001). Multivariate analysis showed the effect of age on PIF was independent of the disease grade. elderly patients with COPD, even when in a stable clinical condition, may be unable to gain optimum benefit from their inhaler.

Effects of Inhaled Corticosteroids on Mortality and Hospitalisation in Elderly Asthma and Chronic Obstructive Pulmonary Disease Patients

Asthma and chronic obstructive pulmonary disease (COPD) are common conditions that have substantial effects on daily functioning and medical resource utilisation. In elderly populations, the use of inhaled corticosteroids (ICS) as a mainstay of treatment in asthma has long been accepted whereas the appropriateness and extent of use of ICS in COPD is not as clear. This paper reviews data associated with ICS treatment in the elderly, specifically characteristics of ICS users, rates of adherence, hospitalisation and mortality associated with ICS treatment. Studies examining the use of ICS in asthma and COPD have generally found that ICS may be underused compared with guideline recommendations or that there are substantial differences between patients who receive ICS and those who do not. Among elderly asthma or COPD patients who receive ICS, there are lower rates of hospitalisation among those who adhere to their treatment plan. Among elderly patients with asthma, the combination of ICS plus long-acting beta-adrenoceptor agonists has been shown to be superior in terms of mortality and hospitalisation compared with either treatment alone. There may be an interaction effect between oral corticosteroids and ICS among elderly COPD patients, although important differences may be present in the clinical characteristics of patients who receive one versus both forms of corticosteroids. A dose-response relationship between ICS and both all-cause and pulmonary-specific mortality has been shown among older COPD patients. Several existing studies are subject to selection bias, as they have identified patients who survived for a specified period, for example, long enough to have received a specified number of prescriptions for ICS. This bias must be further explored. Future research should also clearly delineate asthma and COPD populations in order to identify different benefits from ICS. The use of a claims database that also includes clinical metrics would be useful to identify additional possible outcomes of ICS use. Further, symptom diaries or other patient-reported outcomes, such as health-related quality of life and health status, should be included in studies of ICS among the elderly to identify other benefits that should be considered in treatment selection.

Heavy resistance training increases muscle size, strength and physical function in elderly male COPD-patients—a pilot study

This study investigated the effects of heavy resistance training in elderly males with chronic obstructive pulmonary disease (COPD). 18 Home-dwelling male patients (age range: 65–80 years), with a mean forced expiratory volume in the first second (FEV1) of 46±3.4% of predicted value, were recruited. Baseline and post-training assessments included: Cross-sectional area (CSA) of quadriceps assessed by MRI, isometric and isokinetic knee extension strength, isometric trunk strength, leg extension power, normal and maximal gait-speed on a 30m track, stair climbing time, number of chair stands in 30s, lung function (FEV1) and self-reported health. Subjects were randomized to a resistance training group (RE, n=9) or a control group conducting breathing exercises (CON, n=9). RE performed heavy progressive resistance training twice a week for 12 weeks. 6 RE and 7 CON completed the study. In RE the following improved (P<0.05): Quadriceps CSA: 4%, isometric knee extension strength: 14%, isokinetic knee extension strength at 60°/s.: 18%, leg extension power: 19%, maximal gait speed: 14%, stair climbing time: 17%, isometric trunk flexion: 5% and self-reported health. In CON no changes were found.In conclusion, 12 weeks of heavy resistance training twice a week resulted in significant improvements in muscle size, knee extension strength, leg extension power, functional performance and self-reported health in elderly male COPD patients.

Circuit training for elderly patients with chronic obstructive pulmonary disease: a preliminary study

To examine the efficacy of the circuit training in elderly patients with chronic obstructive pulmonary disease (COPD), we evaluated muscle forces of the upper and lower extremities and respiratory muscles, exercise tolerance and quality of life (QOL) before and after the circuit training in 10 male patients with mild to severe COPD. The circuit training improved muscle forces of the upper and lower extremities and abdominal muscles ( P<0.05), and 6 min walking distance ( P<0.05). Emotional function and mastery in the Chronic Respiratory Disease Questionnaire scores ( P<0.05) were also improved after the circuit training. The circuit training designed in the present study was effective to improve the QOL in elderly COPD patients.

Inhaled corticosteroids in COPD: determinants of use and trends in patient persistence with treatment.

The determinants of a new treatment with inhaled corticosteroids and secular trends in patient persistence with treatment among chronic obstructive pulmonary disease (COPD) patients were investigated. A cohort of 3768 physician-diagnosed, elderly COPD patients was selected between 1990 and 1996 from the health care administrative database of the Régie de l'assurance maladie du Québec. A nested case-control design was used to identify patient and physician characteristics that were associated with a new treatment with inhaled corticosteroids. Treatment persistence with inhaled corticosteroids was also estimated using Kaplan-Meier analysis. In addition to that, changes in treatment persistence over time, from 1990 to 1995, were investigated by estimating the yearly proportion of patients persisting for less than one year. Within the cohort, the yearly percentage of patients filling at least one prescription for inhaled corticosteroids was 42.2% in 1990 and increased to 53.1% in 1995 (P=0.001). Using a conditional logistic regression model, it was found that the patients most likely to initiate a treatment with inhaled corticosteroids were those who had severe COPD (rate ratio [RR] 1.7; 95% CI 1.4 to 2.0), those who were hospitalized for COPD (RR 10.0; 95% CI 5.6 to 17.9), those who consulted a respirologist in the previous month (RR 2.3; 95% CI 1.6 to 3.3) or those who visited more than three different physicians in the previous three months (RR 1.6; 95% Cl 1.3 to 1.9). The proportion of patients persisting with inhaled corticosteroids for less than one year rose by 19.4%, from 47.6% in 1990 to 67.0% in 1995 (P=0.011; test for trend). The use of inhaled corticosteroids increased while patient persistence decreased between 1990 and 1995. Disease severity, as well as recent consultation to a respirologist and multiple visits to a physician, were associated with a strong likelihood of being prescribed inhaled corticosteroids. The cost of this practice is far from negligible, while their clinical impact is still uncertain.

Usefulness of a linear analog scale questionnaire to measure health-related quality of life in elderly patients with chronic obstructive pulmonary disease.

To examine the validity, discriminatory ability, and responsiveness of health-related quality-of-life (HRQoL) questionnaires using a linear analog scale (Quality of Life (QOL) scale) for chronic obstructive pulmonary disease (COPD). Cross-sectional and longitudinal. Outpatient. One hundred two elderly subjects with mild to severe COPD. Scores on the QOL scale, the St. George's Respiratory Questionnaire (SGRQ), and the 36-item Short-Form Health Survey questionnaire (SF-36) and various clinical parameters were recorded. The correlations between these QOL questionnaires and various clinical parameters were then examined. The responses of 31 elderly COPD patients to the QOL scale and the SGRQ before and 3 months after the completion of a comprehensive pulmonary rehabilitation program were compared longitudinally. On cross-sectional study, the QOL scale showed a significant correlation with the total score and three components of the SGRQ. The QOL scale correlated significantly with all components of the SF-36, but the total SGRQ score correlated with only six components of the SF-36, excluding vitality and the mental health index. Both the QOL scale and the total score of the SGRQ correlated significantly with the oxygen cost diagram (OCD), Morale scale, 6-minute walking distance (6MWD), forced expiratory volume in 1 second, and instrumental activities of daily living (IADL) score. When subjects were divided into three groups according to disease severity (mild, moderate, severe) using American Thoracic Society guidelines, the total SGRQ score discriminated between the three groups. The QOL scale could not discriminate between mild and moderate or moderate and severe. On longitudinal study, 3 months after finishing the comprehensive pulmonary rehabilitation program, the QOL scale, the SGRQ, 6MWD, and OCD all showed significant improvement. The difference in the QOL scale after the comprehensive pulmonary rehabilitation program showed a significant correlation with changes in the SGRQ total score and the OCD but not with the 6MWD. The QOL scale is similar to more-complex questionnaires such as the SGRQ in terms of validity and responsiveness for evaluating disease-specific HRQoL in elderly COPD patients. In clinical settings, the QOL scale, as a simple questionnaire, may be useful for disease-specific HRQoL assessments in elderly COPD patients.

Chronic obstructive pulmonary disease (COPD) in elderly subjects: impact on functional status and quality of life

Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and disability. Many studies have investigated factors influencing quality of life (QoL) in middle-aged COPD sufferers, but little attention has been given to elderly COPD. The aim of the present study was to investigate the impact of COPD on QoL and functional status in the elderly. Sixty COPD patients and 58 healthy controls over 65 years old were administered Pulmonary Function Tests, 6min Walking Test (6MWD) for exercise tolerance, the Barthel Index and Mini Mental State Examination (MMSE) for functional status, the Geriatric Depression Scale (GDS) for mood, and the Saint George Respiratory Questionnaire (SGRQ) for QoL. FEV 1 and P aO 2 were reduced in COPD patients. Also the distance walked during 6MWD was significantly shorter for patients than controls (282.5±89.5 vs. 332.9±95.2m; P<0.01). Moreover, COPD patients had significantly worse outcomes for the Barthel Index, GDS and SGRQ. The logistic regression model demonstrated that a decrease in FEV 1 is the factor most strictly related to the deterioration of QoL in COPD patients. Mood was also an independent factor influencing QoL. In conclusion, elderly COPD patients show a substantial impairment in QoL depending on the severity of airway obstruction; symptoms related to the disease may be exaggerated by mood deflection.

Protein malnutrition in elderly patients with chronic obstructive pulmonary disease

Background: It has been suggested that hypermetabolism or reduction of total caloric intake or a combination of both conditions occur in malnourished patients with chronic obstructive pulmonary disease (COPD). It is hypothesized that protein malnutrition plays a role in the metabolism of malnourished elderly COPD patients.Methods: Thirteen COPD patients (mean age: 75.7 years) with severe obstructive ventilatory disorder were divided into two groups: body mass index greater than 20 (group N; n = 8) and less than 20 (group L; n = 5). A nutritional survey and metabolic study were performed.Results: Energy balances appeared more highly positive in group L than in group N and serum concentrations of total protein, albumin and transferrin tended to be lower in group L than in group N (all showed no statistically significant difference). The mean protein digestibility did not show any significant difference between the two groups, suggesting that group L subjects digested and absorbed the ingested dietary protein normally. Mean nitrogen balance was more highly positive in group L than in group N. The FEV1 decreased significantly with increases in the basal metabolic rate (BMR), total daily energy expenditure and urinary nitrogen excretion, respectively (all P &lt; 0.05). PaO2 was positively and significantly correlated with serum concentrations of albumin and transferrin (P = 0.001 and P &lt; 0.05), respectively. Body mass index (BMI) was negatively correlated with BMR (P &lt; 0.05).Conclusions: It is suggested that malnourished COPD patients with lower BMI showed enhanced protein and energy metabolism. Thus, it is likely that malnourished elderly COPD patients could improve through not only supplementation of total carolic intake but also sufficient protein intake.

Effect of sustained release of theophylline on pulmonary physiologic function in elderly patients with chronic obstructive pulmonary disease

We tested the effects of the sustained release of theophylline on the physiologic function of the respiratory system in elderly patients with chronic obstructive pulmonary disease (COPD). We measured the pulmonary function, static respiratory pressures, and ventilation during exercise, before and after the administration of sustained release of theophylline. Unifil, in 12 male COPD patients (mean age 82.1 +/- 0.6 years old). Forced expiratory volume in one second was increased by the administration of 400 mg of Unifil, but not by 200 mg of Unifil, whereas the ratio of residual volume to total lung capacity was decreased by the administration of 400 mg Unifil. Maximum inspiratory pressure was significantly increased after the administration of 400 mg of Unifil. Dyspnea sensation during exercise assessed by the Borg scale was reduced by the administration of 400 mg of Unifil. These results indicate that the treatment with the greater dosage administration of Unifil is effective to improve the physiological function of the respiratory system in elderly patients with COPD, and it may be the treatment of choice for elderly COPD patients.

Guided self‐care using daily recording of peak expiratory flow and diary description for chronic airflow obstruction in the elderly

Background:Only a few studies have been reported concerning the effects of guided self‐care programs on elderly patients with chronic airflow obstruction; chronic obstructive pulmonary disease (COPD); and bronchial asthma (BA). The purpose of the present paper was to study the usefulness of guided self‐care in elderly patients with COPD or BA using a diary alone or diary plus daily measurement of peak expiratory flow rate (PEFR).Methods:A prospective and randomized study was performed at the Pulmonary Division of the Tokyo Metropolitan Geriatric Hospital. A total of 212 patients (mean age: 76.6 years) with a clinical diagnosis of COPD or BA with mild or no cognitive impairment was studied. All patients were randomly assigned to one of two groups: group I (diary and measurement of daily PEFR; n = 112) or group II (diary alone; n = 100).Results:There was no significant difference in the mean number of admissions per month between groups I and II. However, the mean duration of hospitalization was shorter in group I (P &lt; 0.05). The group I COPD subjects had fewer (P &lt; 0.05) and shorter (P &lt; 0.02) periods of admission compared with the group II COPD subjects. This remained true after adjusting for gender, age and forced expiratory volume in 1 s (FEV1.0), but there was no such difference observed for BA subjects. Among subjects in group II, those with COPD showed significantly longer periods of admission than BA subjects (P &lt; 0.05). Better compliance with the PEFR description in group I correlated significantly with the shorter mean duration of hospitalization in the group with higher compliance. This was not found in group II (diary alone). Poor compliance was significantly correlated with advancing age (P &lt; 0.04). However, this was not the case for compliance with the diary. Male subjects showed significantly better compliance in diary description than female subjects (P &lt; 0.04).Conclusions:The PEFR recording plus diary notations are useful tools for avoiding hospitalizations due to acute exacerbation of COPD and probably BA in elderly patients. However, a possible limitation is that fewer than half of elderly COPD and BA patients with mild or no cognitive impairment appear to be able to record PEFR properly.

Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire.

Depressive and anxiety symptoms are common in elderly patients with chronic obstructive pulmonary disease (COPD). However, true prevalence of clinical depression and anxiety is uncertain. We thus aimed to assess prevalence of clinical depression and/or anxiety in elderly COPD patients using the Geriatric Mental State Schedule (GMS) and determine severity of clinical depression by the Montgomery Asberg Depression Rating Scale (MADRS). We also aimed to validate the Brief Assessment Schedule Depression Cards (BASDEC) screening test for depressive symptoms against GMS. A university teaching hospital. Subjects comprised 137 (69 men) outpatients with COPD, aged 60 - 89 (mean 73) years. Exclusion criteria were acute respiratory exacerbation or use of oral corticosteroid within 6 weeks, known psychosis, acute or chronic confusion. A GMS score > or =3 is diagnostic of clinical depression, and a BASDEC score > or =7 is classed as "case". GMS was taken as gold standard. Severity of depression was assessed by the MADRS: Mean (SD) one second forced expiratory volume was 0.89 (0.3) litres. Sixty-two subjects (46%) scored as a "case" on BASDEC and 57 subjects (42%) were identified as clinically depressed on GMS. In the depressed the prevalence of anxiety was 37% and in the non-depressed 5%. BASDEC performed well against GMS, having a sensitivity of 100%; a specificity of 93%; a positive predictive value of 91% and a negative predictive value of 100%. Assessment of severity of depression by MADRS showed that 17 subjects (30%) were mildly depressed, 39 (68%) were moderately depressed and one (2%) was severely depressed. Clinical depression and anxiety are common in elderly patients with COPD, though clinical anxiety seems mainly confined to those who also suffer clinical depression. Of those depressed, two-thirds scored in the moderately depressed range. BASDEC is a valid screening tool in this patient group.

Outpatient antibiotic therapy and short term mortality in elderly patients with chronic obstructive pulmonary disease.

To determine the association between outpatient use of oral antibiotics and 30-day all-cause mortality following hospitalization in a group of elderly chronic obstructive pulmonary disease (COPD) patients. A population-based retrospective cohort study. Ontario, Canada. All 26,301 patients, 65 years of age or older, who were hospitalized for COPD between 1992 and 1996 in Ontario. All elderly patients admitted at least once with a most responsible diagnosis of COPD using the Canadian Institute for Health Information database were identified. They were then linked to the Ontario Drug Benefit database to determine the use of antibiotics within 30 days of the index hospitalization and to the Ontario registered persons database to determine the 30-day mortality following their index hospitalization. Outpatient use of antibiotics within 30 days before the index hospitalization was associated with a significant reduction in the 30-day mortality following hospitalization (odds ratio [OR] 0.83, 95% CI 0.75 to 0.92). Use of macrolides had the lowest relative odds for mortality (OR 0.58, 95% CI 0.47 to 0.73), while use of fluoroquinolones had the highest relative odds (OR 0.98, 95% CI 0.84 to 1.15). Use of antibiotics before hospitalization was associated with a significant reduction in the risk of short term mortality among a group of elderly COPD patients who eventually required hospitalization for their disease. These findings support the early use of antibiotics in COPD patients who experience an acute exacerbation.

Quality of life in elderly patients with COPD: measurement and predictive factors

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity in old age. It leads to reduced quality of life (QoL), but the factors that contribute to this are less understood. There is no consensus on measurement of QoL in elderly COPD patients. We assessed (a) factors predicting QoL in elderly COPD out-patients and (b) specificity (SP), sensitivity (SEN), positive and negative predictive values (PPV and NPV) and repeatability of two disease-specific QoL instruments, the Chronic Respiratory Disease Questionnaire (CRQ) and the Breathing Problems Questionnaire (BPQ) in elderly people. All subjects also completed an ADL measure [Nottingham Extended ADL (NEADL)] and a measure of psychological well-being [Brief Assessment of Depression Cards [BASDEC)] as well as a 6-min walk test. Subjects comprised 96 (56 men) elderly out-patients with irreversible COPD aged 70–93 years (mean 78) who were clinically stable for ≥ 6 weeks. Controls were 55 (23 men) aged 71–90 years (mean 78) with normal lung function. All were cognitively intact. Mean FEV 1/FVC in COPD subjects was 45·5 ( se=1·4)% and for controls was 71·4 ( se=1·3)%. Repeatability was good for both BPQ and CRQ with no significant difference. There were no significant differences in specificity and positive predictive values between the two questionnaires but BPQ performed better than CRQ with regard to sensitivity ( P=0·02) and NPV ( P<0·001). A multiple regression analysis was used to identify variables that best predicted BPQ and CRQ in COPD subjects. For BPQ predictive values were NEADL ( P<0·0001); BASDEC ( P<0·0001); age ( P<0·0001); 6-min walk distance ( P=0·001); body mass index ( P<0·05); resting oxygen saturation ( P<0·05); and household composition (living alone or with relatives, P=0·05). In contrast only the following predicted CRQ: NEADL, BASDEC and resting oxygen saturation. Sixteen per cent of the variance in BPQ was accounted for by NEADL score, 9% by BASDEC, 4% by age and 3% by 6-min walk distance (total r 2=0·70). It was concluded that: (1) BPQ provides more valid assessment than CRQ of QoL in elderly COPD subjects; (2) severity of disease in terms of its impact on QoL is not predicted by lung function tests; (3) the most important determinants of QoL are ADL score and emotional status.

ASTHMA AND EXERCISE IN THE ELDERLY

Participation in regular physical activity, with the goal of enhancing functional ability and fitness, is associated with measurable health-enhancing and psychologic benefits. Various types of exercise are now actively prescribed by the medical community for the prevention and treatment of a number of diseases. 66 Obstructive pulmonary disease, including both chronic obstructive pulmonary disease (COPD) and asthma, is a significant cause of functional disability in older adults that is often characterized clinically by progressive breathlessness and increasing physical limitations. Whether exercise training improves aerobic capacity in elderly COPD patients and, in some cases, those with reactive airway disease, still remains unclear. 100 Earlier studies failed to demonstrate this effect, but more recent investigations 40 , 51 using higher levels of intensity or longer duration of training appear to improve functional capacity in older patients with moderate obstructive lung disease (Table 1) . In this article we examine how asthma, or reactive airflow obstruction, alters physical capacity and human performance in the elderly, and the role of exercise training in the management of reactive airways disease among older patients.

Age distribution of patients treated in hospital for chronic obstructive pulmonary disease.

A discharge register maintained by the National Research and Development Center for Welfare and Health was employed to study the use of hospital services, attributable to chronic obstructive pulmonary disease (COPD), in Finland. From a total population of 5 million COPD caused 113,016 hospital treatment periods during 1983-92 of persons aged 35 years or over. In men the need of hospital treatment for COPD started to rise sharply after the age of 50. Men aged 73 had the highest amount of admissions (3962 admissions per 10-year period). Women aged 68 had the highest amount of admissions (802 admissions per 10-year period). The highest admission rate per 1000 inhabitants was found for men at the age of 82 (37.0 admissions per 1000 population/ year) and for women at the age of 77 (3.8 admissions per 1000 population/year). During the 10-year period a total of 27,008 new COPD patients aged 35 or over received hospital care. The highest number of new admissions occurred among both sexes at the age of 71 (750 admissions per 10-year period in men and 233 admissions per 10-year period in women). This means that most of admissions are due to elderly COPD patients seeking treatment repeatedly. As the populations in the developed countries are ageing, the significance of COPD for the health care system is growing.