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Pulmonary Disease in Elderly

Dr S.K.Jindal

Page 4


IV. Miscellaneous respiratory problems

1. Primary alveolar hypoventilation

This may result from either a low perfusion state in the region of central respiratory chemo-receptors or the brain micro-infarcts. Both these changes are more likely in the aged. The syndrome is characterized by chronic arterial hypoxaemia and hypercapnia. The patient therefore, presents a picture simulating that of chronic cor pulmonale and respiratory failure.

2. Obesity hypoventilation syndrome

A clinical picture of chronic hypoxaemia and hypercapnia is seen in obese patients? obesity hypoventilation syndrome. The primary cause in this condition is decreased respiratory centre responsiveness due to alterations in hormonal function. Weight reduction and progesterone therapy is the treatment of choice.

3. Altered breathing

Cheyne-Stokes breathing is common in the elderly. It is characterized by regular cycles of gradually increasing and decreasing depth of respiration. It is perhaps because of hypoperfusion of the respiratory centre. Its presence in patients of congestive heart failure supports this mechanism.

4. Sleep apnoea syndromes (SAS)

Although sleep apnoea syndromes are not age-specific, they tend to occur more commonly in the old because of the factors described earlier i.e. hypoperfusion, micro-infarcts, hormonal and neuromuscular changes. Both central and obstructive sleep apnoea may occur. There are frequent periods of apnoea or hypopnoea during sleep. This causes arterial oxygen desaturation and effects of hypoxaemia.

5. Pulmonary Aspiration

Aspiration of gastric contents is common due to reduced levels of consciousness and gastroesophageal motility problems. This is even more likely in semiconscious and unconscious patients following strokes, seizures or other diseases concurrently present in the aged. While acute massive aspiration may prove to be fatal, pneumonia is a common sequelae of aspiration.

General issues in management

Diagnosis is relatively difficult in view of the limitations posed due to advanced age. Invasive investigations are often fraught with risks due to concurrent diseases. Moreover, the patient himself/herself may not be favourably disposed to several tests.

Disease-treatment in old age is no different although the management poses problems because of increased drug toxicity, poor tolerance and compromised functions of other systems. Choice of drugs is largely similar. Terminal care involving endotracheal intubation, resuscitation and assisted ventilatory management poses important ethical and social issues. In summary, the problems in the elderly are more common and serious but management is rather restrictive. One has to weigh several options to provide care and relief to the diseased.

Table 1: A summary of normal respiratory alterations with age

I. Structural
1. Lung Elasticity Decreased
Compliance Increased
2. Chest wall Rigidity Increased
Compliance Decreased
II. Lung Function
1. Spirometry V.C. Decreased
FRC, RV Increased
2.Diffusion Capacity (DLCO) Decreased
3.Blood gases PaO2 Decreased
PaCO2 Unchanged
pH Unchanged
III. Lung Defences
1. Nonimmunological
Cough reflex Impaired
mucocilliary Impaired
2. Immunological
Phagocytosis Decreased
Microbial killing by macrophages Impaired
Lymphocyte function Impaired

Table 2: Factors influencing disease occurrence and management in old age.

  • A. Age related alterations (Table 1)
  • B. Cumulative Exposures?

    1. Smoking?
    2. Environmental pollution?
    3. Occupational exposures?
  • C. Comorbid conditions?

    1. Systemic illnesses (Diabetes, hypertension etc.)?
    2. Altered function: Neurological, Gastrointestinal, Cardiovascular?
    3. Treatments for concurrent/comorbid conditions: Corticosteroids,? Antihypertensive/antidiabetic drugs?
  • D. Difficulties of diagnosis and treatment?

    1. Atypical presentations Delayed/misdiagnosis?
    2. Problems in performing invasive tests and interventions?

Dr S.K.Jindal, Professor & Head, Department of Pulmonary Medicine,
Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Professor & Head, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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