1998 - Geriatric Respiratory Medicine

Respiratory Medicine4
Geriatric
Edward D. Chan, MD; and
Carolyn H. Welsh, MD
(CHEST 1998; 114:1704-1733)

Key words: asthma; geriatric; lung cancer; nursing home; pneu
pulmonary function; tuberculosis
monia;
Abbreviations: ATS
eases
adults.
American Thoracic Society; CAP com

munity-acquired
pneumonia; CCC Canadian Consensus Con
ference; CPAP continuous positive airway pressure;
Dlco diffusing capacity of the lung for carbon monoxide;
DVT deep vein thrombosis; FRC functional residual capac
ity; HAP hospital-acquired pneumonia; MAC Mycobacte
rium avium complex; MDI
metered-dose inhaler; MOTT
tuberculosis; NHAP nursing home
mycobacteria other thanNSCLC
non-small cell lung cancer;
pneumonia;
acquired obstructive
OSA
apnea; PE pulmonary embolism;
sleep
PEmax maximal expiratory pressure; Pimax maximal inspira
tory pressure; PPD purified protein derivative; REM rapid
small cell lung cancer; SWOG
eye movement; SCLC
Southwest Oncology Group; TR tuberculosis; TLC total
=
pathophysiology, diagnosis, and

often different from those in younger
in which the
treatment
are
Pulmonary Function
in the
Elderly
lung capacity; Vo2max
maximum oxygen
consumption
die United States, the proportion and absolute

Innumber
of individuals older than 65 years of age is
ever
increasing.1 It is estimated that by the year 2020,
older than 65 years of age in the United States

peopleaccount
for 21% of the population. Whereas in
the
"oldest
1990,
old," those at or older than 85 years of
1%
of the total population (3 million
age, comprised
2050
it
is
estimated that this segment will
persons),
by
include at least 15.3 million persons.1 More recently,
the impact of these demographics on health care, from
both a financial2 and clinical viewpoint,3'4 has been
acknowledged. Pulmonary function and exercise abili
ties are often different between geriatric and younger
based on mere probability,
populations. In addition,
are
at
increased
risk for developing
elderly patients
over
time.
The
diseases
pulmonary
presentation of
certain respiratory disorders may also differ in the
elderly, due in part to less respiratory reserve, to
of hypoxic and hypercarbic drive, or to de
blunting
creased perception of dyspnea.5-6 In this review, we will
discuss the physiology of the aging respiratory system
and will attempt to delineate age-related changes from
the impact of disease. We will highlight specific diswill
From the Division of
Pulmonaiy Sciences and Critical Care

Medicine (Dr. Chan), University of Colorado Health Sciences
Center, National Jewish Medical and Research Center; and the
Denver Veteran Administration Medical Center (Dr. Welsh),
Denver, CO.
received June 1, 1998; revision accepted June 29,

Manuscript
1998.
D. Chan, MD, D411, Neustadt
Correspondence to: EdwardMedical
and Research Center, 1400
Building, National Jewish
Jackson St., Denver, CO 80206; e-mail: chane@njc.org
1704
Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2013
Assessment of pulmonary function in the elderly is
complicated
by a number of issues. First, it is often
difficult to ascertain whether the
loss of respiratory
function is due to aging itself or is due to respiratoiy
illness, smoking, or protracted industrial or environ
mental exposure. Second, elderly patients are more
to have concurrent illnesses or deconditioning
likely
that may directly or indirectly influence pulmonary
function. Nevertheless, it has been established that
even in the healthy elderly population, pulmonary
function deteriorates with age.78 In the following
sections, we will review the anatomical and physio
logic
changes in the respiratory system that occur as
a result of senescence.
Changes in the Senescent Lung

One major anatomical change found in the aging
is smaller airway size, principally due to alter
lung
ations in the supporting connective tissues. In a
postmortem study that correlated airway resistive
properties with morphologic measurements, the ma
jor determinant of pulmonary resistance was mean
bronchiolar diameter, which decreased significantly
past age 40.9 These changes of bronchiolar narrow
ing and increased resistance were independent of
any emphysematous changes or of previous bron
chiolar injury. Other anatomical changes associated
with aging include an increase in the diameter of
alveolar ducts with a concomitant change in the
morphology of the alveolar sacs, which become
shallower.10 These morphologic changes are consid
ered to be due to changes in the relative proportions
of decreased elastic tissues and increased collagen
that occur with aging. In aging Lewis rats, Mays et
al11 showed that both the lung collagen concentra
tion and the proportion of type III collagen increase
with age. Although the observed increase in collagen
does not correlate with the known decrease in elastic
recoil with age, the authors speculated that the
increase in proportion of type III collagen may
actually result in a more compliant lung. Study of the
structural changes of collagen with age is complex
Structural
Reviews
because of differences between the tissue types

examined, quantitative differences between the var
ious types of collagen cross-linking, and qualitative
differences between species in cross-linking with
aging collagen.12-14 Collagen cross-linking may be
divided into two major types: that mediated by lysyl
oxidase and that from the nonenzymatic addition of
glucose adducts.13 One hypothesis is that in the lung
an imbalance of the two principal types of crosslinking occurs with age such that
lysyl oxidasederived cross-linking decreases and cross-linking
with glucose adducts increases.12 The accumulation
of such advanced glycosylation products is consid
ered to alter mechanical properties of collagen and
the extracellular matrix, such as decreased solubility
and elasticity.14 In addition to the increase in type III
collagen
along alveolar walls, elastic fibers are de
creased in the aged lung.15 Perhaps such biochemical
are fundamental to physiologic changes
changes
observed in the aging lung. Immunohistochemical
staining using anti-type IV collagen and antilaminin
also revealed increased thickness of the alveolar
basement membrane.15 However, in a limited series
of patients, Vracko et al16 showed no correlation
between the thickness of the basal laminae of the
alveolar epithelium or endothelium with age.
These anatomical changes, in addition to reorien
tation of elastic fibers, likely account for the follow
ing physiologic changes that are present in the senes
cent lung: (1) decrease in die elastic recoil; (2) increase
in pulmonary compliance; (3) decrease in oxygen dif
fusion capacity with age; (4) premature airway closure
leading to ventilation-perfusion mismatching and in
creased alveolar-arterial oxygen gradient; (5) small air
way closure resulting in air trapping; and (6) decreased
expiratory flow rates. These functional changes mimic
those observed in emphysema.17
Structural
Changes in the Chest Wall and Muscles
of Respiration
lungs with
the
thoracic
and
muscles
also
age,
cage
respiratory
Chest
wall
decreases
due
change.
compliancecalcification of interto
age-associated kyphoscoliosis,
costal cartilages, and arthritis of the cos tovertebral
joints. This increased rigidity of the thoracic cage
leads to a greater contribution to breathing from the
diaphragm and abdominal muscles and a lesser
contribution from thoracic muscles. The prevalence
of diaphragmatic defects, resulting in the loss of
continuity of the diaphragm, also increases with
age.18 How these defects in the diaphragm relate to
the diminution of diaphragm strength with age, as
measured by the maximum transdiaphragmatic pres
sure with either maximal sniff or cervical magnetic
In addition to alterations noted in the
stimulation, is not exactly known.1920 Neither atro

phy nor change in muscle fiber types occurs with age
in the diaphragm, and, thus, they cannot account for
the decrease in diaphragmatic strength.18-2122 This

age-related decrease in diaphragmatic strength may
predispose
elderly patients to respiratory fatigue in
illnesses that require high minute ventilation.
Although expiration is mainly a passive process,
the lateral internal intercostal muscles also actively
contract during expiration and may be important in
nonventilatory activities such as coughing and sneez
ing. In contrast to the preservation of diaphragmatic
muscle mass with
these
intercostal
age,
"expiratoiy
muscles," and to a lesser extent the inspiratory inter

costal muscles, undergo atrophy with a decrease of
7% in the mean cross-sectional
approximately 20 and
respectively, in subjects after die fifth decade.22
area,
Changes in Pulmonary Function with Age

The structural changes in both the chest wall and
lungs outlined above produce predictable changes in
the pulmonary function tests in elderly patients.
in
There is
a progressive decrease
the vital capacity
due to: (1) increased stiffness of the chest wall; (2)
loss of elastic recoil of the lung; and (3) decreased
force generated by the respiratory muscles.7 Due to
the same mechanisms, there is an increase in the
residual volume such that the total lung capacity
(TLC) remains fairly constant (Fig 1). The functional
residual capacity (FRC) also increases with age,
although to a lesser degree because this increase is
counteracted slightly by a stiffening of the chest
wall.23 The site at which the small airways begin to
close during expiration may shift more distally in the
airways; as a consequence, the airways close at a
smaller exhaled tidal volume, thus increasing the
volume. The closing volume begins to exceed
closing
the supine FRC at about 44 years of age, and to
exceed the sitting FRC at approximately 65 years of
age.24 The significance of this is that the terminal
bronchioles close in the dependent parts of the lung
during tidal breathing, thus contributing to the re
duced arterial oxygen tension found in elderly
people.
In a study of > 400 subjects aged 70 years or
older living at home in a nonmining town in South
Wales, Burr et al25 showed that there was a progres
sive decline in FEVX and FVC with age, independent
of smoking or environmental exposure. Although
these cross-sectional data do not necessarily apply to
a given individual because subjects with low FEVX
and FVC may not survive into older age, they do
suggest that in a relatively healthy population spiro
metric functions decline with age.25 It has been
estimated that FEVX decreases by 30 niL/yr in men
CHEST / 114 / 6 / DECEMBER, 18
1705
elderly. The ventilation-perfusion mismatch

that
ing ensues from the closure of small airways, the
airflow limitation that results from bronchiolar and
alveolar duct changes, the increase in collagen con
tent of the alveolar walls, and the decreased alveolar
surface area may all contribute to a higher alveolararterial oxygen gradient. Due to this loss of alveolar
surface area, it has been estimated that, even in
healthy nonsmokers, there is a decline in the diffus
ing capacity of the lung for carbon monoxide (Dlco)
of 2.03 mL/min/mm Hg per decade from middle age
onward for men and a decrease of 1.47 mL/min/mm
Hg per decade for women.33 For younger women 25
to 46 years of age, there was a lesser decline of 0.54
mL/min/mm Hg per decade, suggesting a protective
hormonal effect prior to menopause.
Numerous studies have shown that Pa02, both at
rest and in exercise, decreases with age. Regression
equations have been derived to normalize for the
decline in Pa02 that is seen as a result of aging. Using
the supine position in nonsmoking healthy subjects,
Sorbini et al34 showed that there was a linear, but
reciprocal, relationship between age and Pao2Xwith a
regression equation of Pao2 109 (0.43 age).
Others have also demonstrated, at or near sea level,
that the Pa02 was inversely related to age with
similar, but varying, correction factors.34~36 How
ever, more recently it has been shown that the
decrease in Pao2 with aging is not linear after age
65.37 In this study, arterial blood gas tests were
analyzed in 194 nonsmoking subjects ranging in age
from 40 to 90 years.37 Stratifying the results by
5-year age intervals, the investigators found a clear
decline in Pao2 up to 70 to 74 years of age, followed
by a slight rise in Pa02 from ages 75 to 90 years.
Thus, in the healthy elderly population between ages
65 and 90 years, Pao2 remains relatively stable at
about 83 mm Hg at sea level; this plateau may be due
to a survival effect.3738 Moreover, for the group
ranging in age from 40 to 74 years, body mass index
and PaC02 also influenced the Pa02, whereas for the
group > 75 years of age, there was no correlation
with age, body mass index, or Paco2.37 These
in the Pa02 are magnified by the lower
changes
cardiac output that is seen more frequently in the
elderly, which results in increased oxygen extraction,
reduced mixed venous saturation, and thus also
reduced Pa09.
in the
VC'
VC
FRC
FRC
NORMAL
LUNG
AGED
LUNG
Figure 1. Schematic representation of lung volume changes

associated with aging. Note that with senescence, there is a
decrease in the inspiratory reserve volume (IRV), the expiratoiy
reserve volume (ERV), and the vital capacity (VC). There is a
increase in residual volume (RV) and functional
corresponding
residual capacity (FRC) such that the TLC remains about the
same. TV
tidal volume
=
and by 23 mL/yr in women who are nonsmokers and

that the rate of decline is even greater after age 65.26
In grain elevator workers, the annual decline in lung
function was greatest in the group that was > 50
years of age, regardless of smoking history.27 The
decline in FVC in nonsmoking men is estimated to
be 14 to 30 mL/yr, and for nonsmoking women, 15 to
24 mL/yr.24>28 The potential role of oxidants in
mediating the decline in lung function with age was
assessed in a survey of 178 men and women aged 70
to 96 years.29 These preliminary results revealed that
intake of the antioxidant vitamin E was associated
with a significantly higher FEVX and FVC, suggest
ing that cumulative exposure to oxidants (whether
or exogenous) may lead to an ageendogenous
associated decline in lung function.
Measurements of respiratory muscle strength also
show a diminution with age, although the relative
contribution of the diaphragm or the intercostal mus
cles to this decrease is not well characterized.20'22 In
two relatively small studies, the maximal inspiratory7
pressure (Pimax) and maximal expiratoiy/ pressure (PE
max) decrease with age, especially in women older than
55 years of age.30'31 A more recent and larger study of
65 to 85-year-old healthy subjects also noted a decline
in Pimax and PEmax with age, although the age-related
decline was greater in men.32 These investigators were
able to derive reference equations for both Pimax and
PEmax based on this group of healthy elderly men and
women.32 In general, diaphragm strength is reduced by
about 25% in healthy elderly individuals compared with
young adults.32
Changes In Gas Exchange with Age

Changes in the mechanics of the lungs and chest
wall also may result in altered gas-exchange function
1706
Exercise
and
Ventilatory Response
Elderly
in the
The ability to perform physical tasks declines with

advancing age. Normal young adults are limited in
exercise by cardiovascular adaptability (conditioning)
Reviews
dence between the sexes may indicate investigator

bias, because older men who smoke and wheeze are
likely labeled as having emphysema or bron

age-matched women with similar symp
tom complexes.64-65 Combining data from both sexes,
the incidence of asthma was essentially constant over
the age range of 20 to 70+ years, with an incidence
of 2 to 3 cases per 1,000.63 Similarly, a study from
more
chitis than
Tecumseh, MI, showed that the incidence of asthma

in patients older than 60 years of age was 5 cases per
studies have shown

prevalence
that
the
of asthma
consistently
although prevalence
in
8
10%
childhood
to
of the
peaks
(approximately
and
declines
adulthood
population) 5 to 6% of during
young
the population), there is
(approximately
another prevalence peak in subjects older than 60
years of age, estimated to be approximately 7 to
9% 57,63,66-69 \n a conort 0f > I^OOO subjects, the
65 to
prevalence for asthmaforwasmenhighest inandthein the
55
(3.6%)
age group
74-year-old
to 64-year-old age group for women (4.8%).70 More
recently, Enright et al71 reported an asthma preva
lence of 6% among 5,000 elderly participants in the
Cardiovascular Health Study. The prevalence of
bronchial hyperreactivity in the elderly may be even
greater. Data collected from the National Center for
Health Statistics from 1965 to 1984 revealed that the
for asthma or frequent wheezing in the
prevalence
65 to 74-year-old age group was 10.4%, the highest
in any adult age group.52 In a random group of 160
elderly subjects > 65 years old, a positive result for
the methacholine challenge test was found in 12 and
43% of the subjects (defined as a 20% fall in FEVX
with a methacholine concentration of < 1.0 |xmol
and < 6.13 [Jimol, respectively).72 In southern En
gland, bronchial hyperresponsiveness was found to
be greatest in the 55 to 64-year-old age group, with
a prevalence of 24%.73 Although many of these cases
are related to chronic bronchitis and/or tobacco smok
ing, an important long-term implication of bronchial
is that there is a further increase
hyperresponsiveness
in the rate of age-related decline of lung function when
compared to age-matched control subjects without
bronchial hyperresponsiveness.73"76
New-onset asthma in the elderly is not widely
appreciated.59 In a community survey from south
Wales, 6 of 27 (22%) elderly patients with asthma
developed their first symptoms after age 65.57 Alter
native considerations in the elderly with "new-onset
asthma" include recrudescence of childhood or
early-adulthood asthma, a delay in the diagnosis of
asthma, or a misdiagnosis of asthma in a patient with
COPD or heart failure. Approximately one third of
those in remission from childhood asthma frequently
have recurrence after age 45.69-73 Many elderly
patients with new-onset asthma have had symptoms
1,000.66'67 Several
1708
consistent with asthma for years before their
diagno
raising the possibility that these patients did not

have late-onset asthma but rather "missed" asth
ma.7778 An elevated prediagnosis serum IgE level77
or sputum eosinophilia level59 are predictive of a
subsequent diagnosis of asthma. In a study charac
terizing the clinical profiles of elderly individuals
with long-standing vs recently acquired asthma, Braman et al58 found that half of 25 elderly nonsmoking
patients older than 70 years of age who had asthma
developed the disease after 65 years of age. Both
long-standing and recent-onset elderly patients with
asthma were indistinguishable by symptoms, imme
diate hypersensitivity skin testing, or IgE levels,
although the former group was more likely to have a
history of atopy and had a significantly greater
degree of airflow limitation even after pharmacologic
bronchodilation. This lack of reversibility suggests
that chronic asthma may lead to a persistent airflow
obstruction that may physiologically be similar to
chronic bronchitis or emphysema.58'79-80 Although
aging itself may be associated with the loss of
pulmonary elastic recoil, as outlined in the previous
section, the major determining factor for irreversible
airflow limitation in the elderly asthmatic is the
severity and chronicity of the asthma.65 Small airway
sis,
narrowing is significantly greater in long-standing

elderly patients with asthma than in age-matched
control
subjects.81
Diagnostic Issues of Asthma in the Elderly

Diagnostic criteria for asthma in the elderly are
the same as that in the younger population, although

there is a greater differential diagnosis in the geriat
ric patient who presents with episodic wheezing,
dyspnea, and cough. Other diagnoses to consider
include respiratory tract tumors, laryngeal dysfunc
tion, chronic bronchitis, emphysema, recurrent aspi
ration, constrictive bronchiolitis, herpetic tracheobronchitis, sarcoidosis, congestive heart failure
("cardiac asthma"), hypersensitivity pneumonitis,

pulmonary embolus, and angiotensin converting en
zyme inhibitor-induced cough or angioedema.65'8283
Asthma triggers in the elderly are similar to those in
younger patients with asthma; they include viral
infections, environmental allergens or irritants, emo
tional triggers, and adverse drug effects.83 Viral
infection, chronic sinusitis, and gastroesophageal re
flux disease appear to play a larger role in the initial
presentation and exacerbation of geriatric asth
ma.69-84 Compared to young asthmatics, however,
the prevalence of allergic asthma in elderly patients
is considerably lower.65-8586 Moreover, the sensitivity
Reviews
dence between the sexes may indicate investigator

bias, because older men who smoke and wheeze are
likely labeled as having emphysema or bron

age-matched women with similar symp
tom complexes.64-65 Combining data from both sexes,
the incidence of asthma was essentially constant over
the age range of 20 to 70+ years, with an incidence
of 2 to 3 cases per 1,000.63 Similarly, a study from
more
chitis than
Tecumseh, MI, showed that the incidence of asthma

in patients older than 60 years of age was 5 cases per
studies have shown

prevalence
that
the
of asthma
consistently
although prevalence
in
8
10%
childhood
to
of the
peaks
(approximately
and
declines
adulthood
population) 5 to 6% of during
young
the population), there is
(approximately
another prevalence peak in subjects older than 60
years of age, estimated to be approximately 7 to
9% 57,63,66-69 \n a conort 0f > I^OOO subjects, the
65 to
prevalence for asthmaforwasmenhighest inandthein the
55
(3.6%)
age group
74-year-old
to 64-year-old age group for women (4.8%).70 More
recently, Enright et al71 reported an asthma preva
lence of 6% among 5,000 elderly participants in the
Cardiovascular Health Study. The prevalence of
bronchial hyperreactivity in the elderly may be even
greater. Data collected from the National Center for
Health Statistics from 1965 to 1984 revealed that the
for asthma or frequent wheezing in the
prevalence
65 to 74-year-old age group was 10.4%, the highest
in any adult age group.52 In a random group of 160
elderly subjects > 65 years old, a positive result for
the methacholine challenge test was found in 12 and
43% of the subjects (defined as a 20% fall in FEVX
with a methacholine concentration of < 1.0 |xmol
and < 6.13 [Jimol, respectively).72 In southern En
gland, bronchial hyperresponsiveness was found to
be greatest in the 55 to 64-year-old age group, with
a prevalence of 24%.73 Although many of these cases
are related to chronic bronchitis and/or tobacco smok
ing, an important long-term implication of bronchial
is that there is a further increase
hyperresponsiveness
in the rate of age-related decline of lung function when
compared to age-matched control subjects without
bronchial hyperresponsiveness.73"76
New-onset asthma in the elderly is not widely
appreciated.59 In a community survey from south
Wales, 6 of 27 (22%) elderly patients with asthma
developed their first symptoms after age 65.57 Alter
native considerations in the elderly with "new-onset
asthma" include recrudescence of childhood or
early-adulthood asthma, a delay in the diagnosis of
asthma, or a misdiagnosis of asthma in a patient with
COPD or heart failure. Approximately one third of
those in remission from childhood asthma frequently
have recurrence after age 45.69-73 Many elderly
patients with new-onset asthma have had symptoms
1,000.66'67 Several
1708
consistent with asthma for years before their
diagno
raising the possibility that these patients did not

have late-onset asthma but rather "missed" asth
ma.7778 An elevated prediagnosis serum IgE level77
or sputum eosinophilia level59 are predictive of a
subsequent diagnosis of asthma. In a study charac
terizing the clinical profiles of elderly individuals
with long-standing vs recently acquired asthma, Braman et al58 found that half of 25 elderly nonsmoking
patients older than 70 years of age who had asthma
developed the disease after 65 years of age. Both
long-standing and recent-onset elderly patients with
asthma were indistinguishable by symptoms, imme
diate hypersensitivity skin testing, or IgE levels,
although the former group was more likely to have a
history of atopy and had a significantly greater
degree of airflow limitation even after pharmacologic
bronchodilation. This lack of reversibility suggests
that chronic asthma may lead to a persistent airflow
obstruction that may physiologically be similar to
chronic bronchitis or emphysema.58'79-80 Although
aging itself may be associated with the loss of
pulmonary elastic recoil, as outlined in the previous
section, the major determining factor for irreversible
airflow limitation in the elderly asthmatic is the
severity and chronicity of the asthma.65 Small airway
sis,
narrowing is significantly greater in long-standing

elderly patients with asthma than in age-matched
control
subjects.81
Diagnostic Issues of Asthma in the Elderly

Diagnostic criteria for asthma in the elderly are
the same as that in the younger population, although

there is a greater differential diagnosis in the geriat
ric patient who presents with episodic wheezing,
dyspnea, and cough. Other diagnoses to consider
include respiratory tract tumors, laryngeal dysfunc
tion, chronic bronchitis, emphysema, recurrent aspi
ration, constrictive bronchiolitis, herpetic tracheobronchitis, sarcoidosis, congestive heart failure
("cardiac asthma"), hypersensitivity pneumonitis,

pulmonary embolus, and angiotensin converting en
zyme inhibitor-induced cough or angioedema.65'8283
Asthma triggers in the elderly are similar to those in
younger patients with asthma; they include viral
infections, environmental allergens or irritants, emo
tional triggers, and adverse drug effects.83 Viral
infection, chronic sinusitis, and gastroesophageal re
flux disease appear to play a larger role in the initial
presentation and exacerbation of geriatric asth
ma.69-84 Compared to young asthmatics, however,
the prevalence of allergic asthma in elderly patients
is considerably lower.65-8586 Moreover, the sensitivity
Reviews
of both immediate skin testing and IgE levels de

with age, reducing the negative predictive
value of these tests.84-86-87
The methacholine challenge test, a gold standard
in the diagnosis of hyperresponsive airways, has been
shown to be safe and accurate in the diagnosis of
asthma in elderly subjects.88 The cholinergic bronchoconstrictive response remains stable with age.89
In fact, in a study of normal healthy individuals
without a family history of asthma or allergies,
old and > 60 years old had
subjects < 21 yearsbronchial
significantly
higher
reactivity to methacho
line.90 It was demonstrated in middle-aged and
that smoking and airway atopy
elderly individuals
may act in a synergistic fashion to increase airway
hyperresponsiveness
during methacholine chal
A reduced awareness of bronchoconstriction
lenge.91
in the elderly, despite a greater fall in FEVX than in
young subjects with asthma, during a methacholine
has been described.6 This underperchallengeoftest
acute asthma
bronchoconstriction
ception
during
in
in
result
a
medical
care and
may
delay seeking
contribute
to
the
rate
found in
may
higher mortality
with
asthma.
The
for
mechanisms
elderly subjects
this decreased perception of dyspnea are not well
characterized, but the reduced number or activity of
stretch receptors, the reduced sensitivity of chemoreceptors to hypoxia in the elderly, or the impaired
perception of externally applied resistive respiratory
loads have been hypothesized.43-92 A variation of
> 20% in the
peak expiratory flow rate has been
shown to correlate with wheezing, airway obstruc
tion, and older age in nonsmoking middle-aged and
elderly individuals with a previous diagnosis of asth
ma.93 The Dlco may be helpful in differentiating
emphysema (low Dlco) from asthma (normal to
elevated Dlco).
creases
Prognosis of Asthma in the Elderly

The mortality rate for asthma in many parts of the
world has significantly increased in recent years and
is most striking in patients older than 55 years of
age.57 In Australia, 45% of asthma deaths in 1986
were reported in patients older than 60 year of age.94
Even more worrisome is that a significant number of
these deaths were in patients who were not consid
ered to be at particularly high risk. In England and
Wales in 1985, 58 and 71%, respectively, of the
asthma deaths in men and women occurred in
individuals older than 70 year of age.95 Explanations
for the rising death rates, especially in the elderly,
are speculative and include blunted awareness of
respiratory discomfort, concomitant myocardial dys

function, increased ambient pollution in recent
years, undertreatment of exacerbations, and even,
Older pa
possibly, the overuse of P2-agonists.5-96'97
tients with asthma (those > 65 years of age) have
been shown to be more likely than younger patients
with asthma (those < 40 years of age) to have a
prolonged period of exacerbative
symptoms before
This
being
hospitalized.98
delay, likely due to the
reduced awareness of bronchoconstriction by the
makes objective measurements of the sever
elderly,
of
airflow
limitation such as with a peak flowmeter
ity
especially important.5-83 Physician bias in assessing
the severity of asthma may also contribute to underIn a study comparing clinical and functional
therapy.
features of elderly vs younger patients with asthma,
older patients had a larger than predicted decrease
in pulmonary function even though physician-as
sessed severity was similar in both groups.80 A less
pronounced tachycardia and pulsus paradox in the
elderly patient with acute asthma than in younger
patients with asthma, despite similar airway obstruc
tion and blood
lull clinicians
gas abnormalities, may
into perceiving an asthma exacerbation as less severe

in the
for any given level of airway obstruc
tion.98 Age itself also can be an important factor in
elderly
determining the prognosis of asthma because of the
greater prevalence of other diseases coincident to, or
complicated by, asthma in the elderly. In a 7-year
longitudinal study of 24 elderly patients with asthma
older than 70 years of age, corticosteroid depen
dency remained in most patients (21 of 24), and
complications of therapy were common, including
diabetes mellitus, systemic hypertension, and various
infections.99 In the 11 patients who
life-threatening
died in the follow-up period, most from a "cardiac"
cause, the baseline FEVX was not predictive of
deaths from asthma or from all causes.
Therapy of Asthma in the Elderly
Asthma therapy in the elderly is similar to that for
younger individuals and should generally follow the
step care recommendations of the National Asthma
Education Program,96 beginning with the inhalation
of
on a relief basis for
mild asthma, and

p2-agonist
to
the
of
addition
inhaled
or oral corti
progressing
costeroids for more severe cases. Some investigators

have shown that the therapeutic response to inhaled
p2-agonists decreases with increasing age100-101 con
sistent with findings that P2-receptor number and
function decline with age.102-103 However, in a more
recent study, age did not influence the response to
inhaled bronchodilators in stable patients with asth
ma.104 In this randomized crossover study, both
young patients with asthma (18 to 25 years of age)
and elderly patients with asthma (> 65 years of age)
responded equally well to either inhaled albuterol or
ipratropium bromide, although the magnitude of
CHEST/114/6/DECEMBER, 1998
1709
response in both age groups was greater with albu

terol. In a large study that characterized > 1,000
bronchodilator responses, there was no systemic
correlation between a significant response and
(ATS)
age.105 Thus, the American >Thoracic Society
criteria for improvement of 12% and > 200 mL in
FEVX for a significant bronchodilator response is
considered appropriate for all age groups. The role
of anticholinergic therapy with ipratropium in
asthma is not well defined, but, theoretically, this
may be an adjunctive bronchodilator in elderly pa
tients with asthma.106 Anecdotally, elderly patients
with asthma appear to require long-term corticoste
roid therapy with greater frequency to control airway
hyperreactivity58'99-106
In the elderly patient with asthma, therapeutic
regimens should be carefully individualized for sev
eral reasons. First, there is a higher incidence of
adverse drug reactions due to altered drug metabo
lism and elimination. Second, medications used to
treat concomitant diseases can lead to multiple drug
interactions or can precipitate asthma exacerbations.
Third, there may be noncompliance with medica
tions due to financial, neuropsychiatric, or physically
disabling disorders such as arthritis. Last, coexisting
disorders that are more prevalent in the elderly and
that may exacerbate asthma include chronic aspira
tion and gastroesophageal reflux.107-108 The use of
inhaled (32-agonists is relatively safe in the elderly,
systemic absorption can lead to
although evenandmild
muscle
tremor. Because asthma and
tachycardia
cardiovascular disease frequently coexist in the el
derly, the treatment of one has the potential to
exacerbate the symptoms of the other. For example,
crisis, cardiac ischemia, and dysrhythhypertensive
mias may be precipitated by the subcutaneous ad
ministration of epinephrine or terbutaline, but there
may be less of a chance of precipitation with inhaled
P2-agonists. In cardiac patients on digoxin or on
drugs that may prolong the QT interval, (32-agonistinduced hypokalemia and QT prolongation may lead
to life-threatening dysrhythmias.106 Theophylline
metabolism may be decreased by congestive heart
failure, by chronic liver disease, or by the concomi
tant use of medications such as cimetidine, calcium
channel blockers, erythromycin, fluoroquinolones,
and allopurinol, which can lead to toxic levels of
theophylline.
Theophylline may also cause urinary
retention in older men83 and may increase the risk of
developingisatrial tachyarrhythmias.109
Although the
ophylline generally not recommended for treat
ment of acute asthma if P2-agonists and corticoste
roids are used properly,110 long-acting theophylline
may be a useful adjunctive agent for the patient with
difficult-to-control nocturnal asthma.111 The
of
array
adverse effects of corticosteroids are well known and
1710
relevant in the elderly population,

particularly
exacerbation
of hypertension and diabetes
including
mellitus, psychiatric disturbances, poor wound heal
ing, impaired immune response, cataracts, myopathy, aseptic necrosis of the femur, and osteoporosis.
To minimize these complications, glucocorticoid
dosage should be reduced as expediently as possible
with use of an alternate day oral regimen or inhaled
corticosteroids once the acute
are con
are
symptoms
trolled. To prevent bone loss in patients on chronic

corticosteroids, more recent trials suggest that the
use of estrogen replacement therapy in the female
patient112 or the use of the diphosphonate etidronate113 along with calcium and vitamin D supple
mentation is efficacious. Oral and topical (3-blockers
may exacerbate asthma. The use of a cardioselective
(31-blocker, such as metoprolol, atenolol, or acebutolol, or the topical agent betaxolol is less likely than
nonselective agents to cause bronchospasms.114
Nonsteroidal anti-inflammatory drugs and aspirin,
commonly used to treat various rheumatologic and
cardiovascular diseases in the elderly, also may exac
erbate asthma in certain subgroups.
The proper use of metered-dose inhalers (MDIs)
can be difficult to achieve even for the nonelderly. In
the elderly, suboptimal timing of actuation with
inhalation and discoordination from neuromusculoskeletal diseases are well documented.115 Patients
with intellectual impairment may grossly misuse
their MDIs, such as by failing to remove the cap or
by placing the wrong end in their mouths.115 Me
chanical devices that can aid in the optimal delivery
of inhaled bronchodilators include spacers, an
adapter that
helps patients with arthritis actuate their
MDIs, and even breath-activated MDIs (Fig 2).
Spacers have been shown to increase the efficiency
with which inhaled medications are delivered to the
airways, minimizing systemic absorption of P-ago
nists or corticosteroids from the oropharyngeal mu
cosa, thus reducing local and systemic complications
such as mucosal candidiasis, dysphonia, and tachy
cardia.116 However, it cannot be overemphasized
that teaching of the proper technique for MDI use
and the observation of its use by patients themselves
on a frequent basis is of paramount importance.
COPD
in the
Elderly
COPD, defined
as chronic bronchitis or emphy

disease the prevalence of which increases
in the sixth decade, thus making it a disease of the
sema, is
elderly. Because COPD is principally a geriatric

disorder, we have not written a comprehensive re
view but have focused
features of the
our
discussion
therapeutic
on
the salient
armamentarium.
By
Reviews
Figure 2. Mechanical devices that may aid in the
optimal use of MDIs: (A) accordian-style spacer

Kenilworth, NJ); (B) a mask fitted to a spacer, which may be useful for the
(InspirEase; Schering;who
has poor coordination of mouth musculature (AeroChamber; Forest
neurological patient
Pharmaceuticals; St. Louis, MO); (C) OptiHaler spacer (Health Scan Products; Cedar Grove, NJ); (D)
breath-actuated MDI (MaxAir; 3M Pharmaceuticals; Northridge, CA); () adapter for an MDI for
arthritic patient (VentEase; Glaxo; Research Triangle Park, NC); (F) ellipse spacer (Allen and
Research Triangle Park, NC); and (G) a spacer fashioned from ventilator tubing used at the
Hansbury;
Denver Veterans Administration Medical Center.
1989 estimate, there are about 12 million Americans
who have chronic bronchitis and 2 million who have
emphysema.117 Predictors of poor survival in COPD
include low FEV1? the presence of cor pulmonale, an
age of > 65 years, low lean body weight, and resi
dence at higher altitudes.118-120 Considered to be
the fifth leading cause of death in the United
since ciga
largely preventable
risk
factor.
Other risk
smoking
major
factors are less common. Alpha-one antitrypsin defi
ciency, detected in only 1 to 2% of persons with
COPD, and occupational exposures to mineral and
grain dusts can contribute to an accelerated loss of
the majority of smokers do not
lung function.121 As
there
is likely a yet unexplained,
develop COPD,
risk
multiple-factor genetic for COPD as well.
For COPD, therapy with proven impact on outcome
includes smoking cessation and oxygen therapy, when
medically indicated. It is never too late in the course of
a disease for a patient to stop smoking, as smoking
cessation slows the decline in lung function induced by
cigarettes.122-124 Smoking cessation also is associated
with lower
risk after 6 weeks as well as an
States,117 COPD
rette
is
is the
operative
immediate drop in carbon monoxide levels.125 Studies

from the Nocturnal Oxygen Therapy Trial and the
Medical Research Council have shown that continuous
oxygen tiierapy in hypoxemic patients with COPD
improves survival and that survival is directly related to
the number of hours of oxygen use per day.126-128
Oxygen therapy also has been shown to improve quality
of life, including benefits in sleep, exercise tolerance,
neuropsychiatric
testing, and reduction in secondary
and
nocturnal arrhythmias.129130 Noctur
polycythemia
nal oxygen supplementation has further been shown to
be safe without a clinically significant rise in PaC02
during sleep in patients with stable COPD.131
Except for oxygen treatment, drug therapy for
COPD has so far failed to have an impact on outcome.
Pharmacologic medications are similar to those out
lined in the previous section for asthma, but they also
include early use of anticholinergics.123 Patients with
COPD may respond to inhaled anticholinergics despite
a lack of response to inhaled P2-agonists.132 In fact,
ipratropium bromide is considered a first-line therapy
in patients with COPD, with recent emphasis on higher
doses (eg, 3 to 6 puffs qid to control symptoms, increase
1711
exercise tolerance, and improve baseline lung func

tion).133-135 Combination MDIs with ipratropium bro
mide and albuterol (Combivent; Boehringer In
gelheim; Ridgebury, CT) have been more effective
than eidier agent alone in achieving improvements in
pulmonary function tests and may theoretically provide

better compliance because of less frequent dosing.136
The use of theophylline in the treatment of COPD is
controversial, but, in addition to bronchodilation, it may
improve diaphragmatic strength, may prevent fatigue,
may improve nocturnal symptoms.137"139 It is estimated
that 10 to 25% of patients with COPD respond to
corticosteroids.123-140 Responsiveness is not reliably
predicted by eosinophils or by FEVX response to
bronchodilators. Accordingly, a trial of corticosteroids
with objective measurements for response (eg, an
increase in FEV: of at least 20% and 200 mL) should
be considered in recalcitrant cases.141 The benefits of
empiric antibiotics in acute exacerbations have been
evaluated with a recent meta-analysis of nine random
ized, placebo-controlled trials that showed only small
benefits for the use of antibiotics in an exacerbation.142
Patients who appeared to benefit most from antibiotics
were older, had more severe disease as measured by
pulmonary function tests, and had purulent sputum. In
these patients, it appears prudent to administer empiric
antibiotics to cover for Streptococcus pneumoniae,
influenzae, and Moraxella catarrhalis.143
Haemophilus
Medication toxicity and interactions, especially with
are more common than for younger
theophylline,
These
issues were discussed above in detail in
patients.
the asthma section of this review.
Pulmonary rehabilitation, which is composed of
(1) exercise training, (2) patient education, (3) psy
chosocial, nutritional, and respiratoiy therapy coun
seling, (4) smoking cessation, and (5) optimization of
medication, is recommended for patients with severe
symptoms or with limited functional status. Recon
ditioning skeletal muscles does not improve lung
function, but exercise tolerance, dyspnea, and, thus,
quality of life generally improve with rehabilitation
programs, although a clear benefit on outcome is
variable in randomized trials.144-146 More recently,
rehabilitation was shown to increase the
pulmonary
exercise capacity of "older" elderly who had COPD
(ie, those patients ^ 75 years old and with mean age
[ SD] of 78 1 year), a beneficial effect similar to
that seen with younger patients with COPD (mean
age, 64 1 years).147
Pulmonary Emrolism
in the
Elderly
Epidemiology of Pulmonary Embolism in the

Elderly
A recent assessment
300,000
to
600,000
cases
suggests that there

of
are
pulmonary embolism
1712
(PE) or deep vein thrombosis (DVT) each year in the

United States.148 The risk for venous thromboembolism rises with age.149150 In Italy, the incidence of
venous thromboembolism peaks in the seventh to
decade of life.151 In the United States, the
eight
annual incidence at ages 65 to 69 is estimated to be
1.3 and 1.8/1,000 population, respectively, for DVT
and PE, which by ages 85 to 89 increases two-fold to
2.8 and 3.1/1,000 population.152 The presence of
venous thromboembolism is associated with in
creased mortality rates and an 8% 1-year recurrence
rate.152 The antemortem diagnosis of PE is often
missed in autopsy series, especially in the elderly153
In a postmortem study of 54 patients with anatomi
cally major PE, the presence of either pneumonia or
of age > 70 years was strongly associated with a
missed antemortem diagnosis of PE.154
General risk factors for venous thromboembolism
include trauma, surgery, pregnancy, stasis, genetic
risks (especially activated protein C resistance), and
prior thromboembolic episodes. Elder-specific risk
factors for venous thromboembolism include: (1)
coagulation
changes such as increases in fibrinogen
and other procoagulant levels and a decline in
antithrombin levels with aging; (2) the association of
advanced age with other risk factors for thromboem
bolism such as malignancy, hip fracture, varicose
veins, heart failure, and stroke; and (3) stasis issues
such as decreased mobility and decreased leg mus
culature, which may result in decreased venous
return.155156 Whether the laboratory evidence for
hypercoagulability in itself relates to increased risk of
vascular thrombosis is not clear, as a single study of
25 healthy centenarians revealed a marked hypercoagulable state compared to younger individuals.157
Diagnosis and Treatment of Thromboembolism

Even though the likelihood of PE rises with age,
in establishing a diagnosis also increases
difficulty
with age for a variety of reasons. First, a diagnosis of
PE
not be considered because shortness of
may
breath and chest pain are attributed to other condi
tions that are prominent in the aged, including
COPD, angina, or congestive heart failure.158 For
elderly stroke patients who are at increased risk for
thromboembolism, neurological impairment may ob
scure the clinical presentation of pulmonaiy throm
boembolism. Second, due to a blunted perception of
that may occur with age,5-6 the elderly
dyspneawith
thromboembolism may delay seeking
patient
medical care or may mistakenly attribute dyspnea to
the effect of aging itself. In 37 subjects with PE who
were older than 64 years of age, only 1 had the classic
symptom triad of dyspnea, pleuritic chest pain, and
hemoptysis.159 Third, impedance plethysmography,
Reviews
which is used for detecting DVT, may yield falsepositive results in patients with congestive heart
failure.156 Fourth, ventilation-perfusion scans are
more difficult to interpret in the elderly. This diffi
is due both to the presence of comorbid
culty
illnesses that cause scan abnormalities and to the
slower clearance of radioaerosols even in aged nonsmokers without lung disease.160 Thus, in the face of
an indeterminate lung scan, a duplex ultrasound of
the lower extremities should be performed, and if it
is negative, a pulmonary angiography or helical CT
scan may be required to definitively diagnose or
exclude thromboemboli when clinical suspicion re
high.
for venous thromboem
Anticoagulation
therapyshown
has
to improve survival
which
been
bolism,
four-fold compared to no treatment, is the same for
young and older adults.161 In elderly patients with
marginal cardiopulmonary reserve due to preexisting
heart failure or COPD, a small embolus may have a
major adverse effect on hemodynamics or gas ex
a rapid achievement of therapeutic
change. Hence, with
heparin is especially important
anticoagulation
in this population to maximize therapeutic out
come.162 However, the risk of chronic anticoagula
tion with warfarin may be increased in the older
adult who, due to neurological impairment, may be
confused about medication dosing, which can lead to
over or under anticoagulation, or who falls and thus
is at increased risk for a bleeding-related complica
tion.163164 In addition, warfarin interacts with many
medications, including antibiotics,
commonly used oral
diabetic agents, hypolipemics,
anticonvulsants,
and
vitamins,
allopurinol. Most studies examining
the risk of bleeding while on warfarin fail to show a
correlation between age and bleeding risk except for
the "oldest old."165166 The duration of therapy has
traditionally been 3 to 6 months, but in patients with
a continued risk for thromboembolism, longer peri
ods of anticoagulation therapy may be required to
prevent the high probability of recurrence.150 For
the elderly patient with social issues or medical
disorders that preclude long-term anticoagulation
with a filter may be
therapy, vena caval interruption
a viable alternative in preventing immediate PE,
is associated with a
although this treatment likely
DVT.167
risk
of
later-onset
Although age per
higher
se is not a contraindication for thrombolytic therapy,
which is recommended for hemodynamically signif
with an increase
mains
PE, age is associated

preva
lence of comorbid conditions that are associated with
extrapolating from
bleeding risks.156 Furthermore,infarction
the experience of myocardial
studies, intracerebral hemorrhage is a more common compli
cation in the elderly.168 Prophylaxis against throm
boembolism with subcutaneous heparin and/or
icant
pneumatic compression devices should also be con

sidered for the hospitalized elderly patient because
of the higher risk of thromboembolism and the

increased frequency of treatment complications.
Waning
Pneumonia and the Elderly

of the Immune System in the Elderly
and
Although a decline in the innatehas(neutrophil)
been
observed
immunity (lymphocytes)
specific
in the elderly, in many cases it is not clear whether
the defect is primary or secondary to an underlying
in
systemic disorder such as cancer. Furthermore,

vestigators have been unable to substantiate a rela
tionship between the level of cell-mediated or hu
moral immunity and the risk of nosocomial
pneumonia in the elderly.169 Diet and exercise may
age-related changes in the immune

response.170 Macrophage function, including chemotaxis, adherence, and phagocytosis appear to be
largely unaffected by aging. Tests for peripheral
blood-derived natural killer cell function in humans
show little if any age effects, although data from
mouse studies are conflicting.170 In contrast, neutro
and respiratoiy burst appear to be
phil chemotaxis
with
impaired aging.171 The specific immune system,
cell-mediated immunity, appears to be
especially
most vulnerable to the effects of aging,170172 as
evinced by: (1) reduced thrombopoietin levels and
involution of the thymus with aging; (2) diminished
delayed-type hypersensitivity response due to de
creased T-cell proliferation; (3) loss of memory
T-cell function; (4) decreased numbers of T-helper
cells and increased numbers of T-suppressor cells;
(5) reduced interleukin-2 production and reduced
interleukin-2 receptor numbers; and (6) increased
reactivation of tuberculosis (TB) and herpes zoster in
Many of the functional defects in
elderly individuals.
senescent T-cells have been traced to the subcellular
level and consist of defects in signal transduction
among various protein kinases.170
An age-associated decline in humoral immunity, as
evinced by a lower rate of seroconversion and de
creased antibody titer after vaccination, also has
been observed, although this may largely be the
result of a loss of T-helper cell effector function.170
the age-related decline
Although the significancein ofrelation
to the risk for
in antibody response
is
not
established,
elderly patients
firmly
pneumonia
do have a reduced antibody response to influenza
vaccine compared to young adults.173174 However,
because > 80% of deaths from influenza occur in
also influence
patients older than 65 years of age and because the

severity of influenza, it is
recommended that elderly patients and their con-
vaccine may attenuate the
1713
In a recent large
yearly vaccinations.175
> 65
of
old,
study elderly patients years it was shown
that vaccination against influenza is associated with a
in the hospitalization rate for
significant reduction
and
influenza
as well as for all acute and
pneumonia
chronic respiratoiy conditions.176 Furthermore, in
fluenza vaccination has been shown to reduce mor
tality by 40 to 50% from all causes during influenza
seasons, to be cost-effective, and to have no greater
adverse affects compared with placebo in the elder
tacts receive
ly.176177 Despite widespread campaigns advocating

clearly underutilized.178
Currently, the Centers for Disease Control and
Prevention recommends a single-dose immunization
with the multivalent pneumococcal vaccine to all
persons 65 years old and to all adults of any age
with chronic cardiovascular disease, chronic pulmo
nary disease, or diabetes mellitus.179 For those who
received the vaccine when they were < 65 years old
and for whom 5 or more years have elapsed since
receiving the vaccine, a second dose is recom
mended. The clinical efficacy of the pneumococcal
vaccine is modest in the elderly, but it has been
demonstrated to approximate efficacy in the general
in preventing pneumococcal infections
population
and to be cost-effective.180181 Unfortunately, < 10%
of patients who are eligible for the pneumococcal
vaccine receive the immunization.
its use, the vaccine is
>
Epidemiology of Pneumonia in the Elderly

Pneumonia is the fourth overall leading cause of
death and is the leading infectious cause of death in
the elderly.182183 Persons 65 years of age account
for about half of all pneumonia cases.184 In 1993,
pneumonia accounted for more than 600,000 hospi
tal discharges and about 6 million days of hospital
ization among patients ^ 65 years old.185 Elderly
individuals are at a particularly high risk for severe
of
due to decreased
>
consequences
pneumonia
respi
the existence of comorbid diseases

such as COPD, diabetes mellitus, and coronary7
arteiy disease, and the waning of innate and specific
immunity that occurs with aging. In addition, the
more widespread use of an array of immunosuppres
sive drugs such as corticosteroids, cyclosporin, and
cytotoxic agents to treat autoimmune, inflammatory,
or malignant disorders has likely increased the fre
quency and severity of community-acquired pneu
monia (CAP) in the elderly. Thus, although age in
itself may not be a strong independent predictor for
increased mortality, it is linked with increased risk
due to comorbid factors.186
The majority of cases of bacterial pneumonia are
acquired from the microaspiration of colonized oro
pharyngeal flora.187 The elderly may be at increased
ratory
reserve,
1714
risk of such aspiration from a depressed level of

consciousness, oropharyngeal dysynchrony, or alter
ations in deglutition due to stroke, senile dementia,
medications, or Parkinson's disease.188-189 Using a
radioactive tracer, Kikichi et al190 found that 10 of 14
(71%) elderly patients with CAP had silent aspiration
compared to only 1 of 10 age-matched control
subjects. Risks for bacterial colonization of the oro
pharynx and subsequent aspiration are more com
mon in the elderly, including periodontal disease,
use of antacids or H2-antagonists, malnutrition, and
more frequent hospitalizations and institutionalizations. In addition to these potential risk factors for
aspiration, the mucociliary clearance of even healthy
and nonsmoking older subjects has been shown to be
decreased compared to younger volunteers.191
Etiologic Agent of Pneumonia in the Elderly

Even in the most exhaustive prospective studies on
hospitalized patients with CAP, an etiologic agent is

found in only about 50% of cases. Furthermore, the
unreliability of sputum Gram's stain and culture and
the impracticality of serologic testing in the acute
setting lowers the diagnostic yield. Almost invariably,
the most common isolate is
Streptococcus
pneu
(estimated to cause 20 to 30% of CAP cases

elderly), followed by, in various orders, non-
moniae
in the
typable Haemophilus influenzae, Legionella pneumophila, Chlamydia pneumoniae, and Gram-negative

bacilli. The disproportionate number of cases of L
pneumophila
pneumonia in the elderly may also
account for the higher mortality rate seen in this age
group as Legionella pneumonia is often associated
with a more severe clinical syndrome.192-196 Normal
oropharyngeal flora, composed of a mixture of aero
bic and anaerobic
bacteria and often discounted

when found on sputum cultures, may also account
for a significant number of cases of CAP.197 In fact,
it has been estimated that the overall incidence of
anaerobic lung infection caused by the aspiration of
mouth flora may be as high as 21 to 33% and that
anaerobic organisms such as Bacteroides spp, Fusobacterium spp, and Peptostreptococcus spp may be
secondary only to S pneumoniae as a cause of
Although Mycoplasma pneumoniae

pneumonia occurs principally in young adults and
rarely requires hospitalization, severe cases of pneu
monia due to this organism have been documented,
even in previously healthy elderly persons.199'200 It
was recently reported that the age-specific hospital
ization rate for CAP due to M pneumoniae rises
CAP.197198
about eight-fold between the groups 35 to 49 years

and 80 years of age and over, emphasizing the
significance of mycoplasma as a pathogen in older
adults.201 CAP due to Staphylococcus aureus is less
Reviews
but is associated with a

poorer prognosis. Secondary staphylococcal or pneu
mococcal pneumonia should also be of concern
during outbreaks of influenza pneumonia. The inci
dence of Gram-negative pneumonia is considered by
some to be increased in the elderly, but in certain
series, may be related to institutionalization and
to age itself.182202 The
hospitalization rather than
for
rate
Gram-negative bacilli
oropharyngeal carriage
is estimated to be 6 to 9% for the healthy elderly
22% for those living in
population, approximately
and
nursing homes, approximately 40% for hospital
ized elderly patients.203 Age per se has not been an
risk for Gram-negative colonization,
independent
but in institutionalized elderly patients the presence
of respiratory disease and debilitation are risk fac
tors.202-204 Other studies have also shown that diabe
tes mellitus, ethanol abuse, and incontinence are risk
factors for Gram-negative pharyngeal coloniza
tion.204-205 Influenza pneumonia in the elderly is
and
particularly associatedinwiththeincreased morbidity
of
setting underlying
mortality, especially
disorders. Individuals > 65 years
cardiopulmonary
of age likely account for about 90% of deaths due to
influenza and secondary bacterial pneumonia.
common
than other
causes
Clinical Presentation of CAP in the Elderly

Many medical illnesses in the elderly, including
pneumonia, have atypical presentations.206 This was
when he stated "in old age,
emphasized by Osier,207
be
pneumonia may latent, coming on without chill;
the cough and expectoration are slight, the physical
signs ill defined and changeable, and the constitu
tional symptoms out of all proportion." Rather than
having respiratory symptoms primarily, patients may
present with a functional decline, confusion, falls,
exacerbation of an underlying illness such as COPD
or angina, or metabolic abnormalities such as renal
failure or hyponatremia.186-208-210 In one study of
male veterans with CAP, only 56% had at
elderly
least one of three respiratory symptoms of cough,
fever, or shortness of breath.209 Moreover, approxi
mately one third of the patients had a normal white
blood cell count and/or absence of a left shift. In this
study, factors that correlated with an "atypical" pre
sentation of pneumonia were increased age, inability
to perform activities of daily living, and a minimental status exam score of < 20. In a retrospective
bacteremic pneumonia in the
study of pneumococcal
of
the patients had respiratory
48.3%
elderly, only
on
symptoms presentation.211 Others investigators
have also noted the absence of fever in the elderly
patient with pneumonia, which may be due to
malnutrition, to different criteria of fever in an
elderly patient with lower than normal basal temper
ature, or to suboptimal methods of temperature

measurements.210-212-213 In a study of 70 elderly
patients with CAP (ages 65 to 97 years), more than
one half had exclusively nonrespiratory symptoms
and more than one third had no systemic signs of
infection such as fever, tachycardia, or neutrophilia.212 In part, these atypical presentations may con
tribute to the increased mortality of CAP in the
elderly due to a delay in seeking medical attention
and/or a delay in diagnosis.
Prognostic Factors of Pneumonia in the Elderly

are hospitalized more
elderly patients
are
more
likely to require
frequently
intensive care support and longer hospital stays due
to an increased incidence of respiratory and nonres
piratory complications, and have the highest mortal
ity rate, accounting for up to 90% of all pneumonia
deaths.186213-214 The annual mortality rate for CAP
and influenza in patients older than 65 years of age
has increased from 145.6 deaths/100,000 population
in 1979 to 209.1 deaths/100,000 population in
1992.183 In 1993, the in-hospital mortality rate for
pneumonia patients older than 65 years of age was
10.7 deaths/100 discharges.185 Most influenza-re
lated deaths in the elderly are not directly due to
they are asso
pulmonary complications, but, rather, events
such as
ciated with secondary cardiovascular
or
strokes.
These
infarction
myocardial
complica
tions may be due to a transient prothrombotic state
in older persons infected with influenza or to hypoxia
in a compromised circulation. Bacteremia in the
elderly signifies a mortality rate in excess of
40% 215,216
As a group,
for CAP,
Since the initial
management of pneumonia
as S aureus, Gram-negative rod,

etiology (defined
or
aspiration, postobstructive pneumonia), and neodisease, an age of > 65 years was a predictor
plastic
outcome.220 Starczewski et al210 found a
of
poor
strong
association between acute confusion at the

is
be useful to identify the

usually empiric,
risk
for
death. A number of
patients at highest
studies have evaluated admission variables that pre
dict outcome in CAP. Such investigations are also
invaluable in helping to assess the need for hospital
ization. Three separate studies have shown that renal
failure, diastolic hypotension, and tachypnea are
in a stepwise logistic regres
predictive of mortality
sion model.217-219 In one of these large prospective
studies of > 400 patients, the 60- to 74-year-old age
group not only comprised the greatest number of
patients with CAP, but also accounted
hospitalized
for 20 of the 26 patients who died from CAP.219 A
more recent study revealed that in addition to vital
sign abnormality, altered mental status, high-risk
it would
1715
time of admission for CAP and subsequent mortality

the elderly. In a recent meta-analysis of > 100
articles on CAP encompassing > 30,000 patients
over a 30-year period, Fine et al221 identified 10
in
prognostic factors that
were associated with the

risk
risk factors, in order of
of
death.
These
highest
odds
include
hypothermia, systolic
descending ratio,
hypotension, neurologic disease, multilobar radio-
graphic pulmonary infiltrate, tachypnea, bacteremia,

disease, leukopenia, diabetes mellitus, and
neoplastic
male gender. In a follow-up study, in which a scoring
system was used to identify adverse prognostic fac
tors, neoplastic disease, an arterial pH of < 7.35,
liver disease, a change in mental status, a respiratoiy
rate of ^ 30/min, a systolic BP of < 90 mm Hg, a
BUN of 30 mg/dL, and a sodium concentration of
< 130 mmol/L were found to be the best predictors
for poor survival.222 Although useful for population
stratification, decisions for individual patients should
not be based solely on the various prognostic indica
tors.186
Although the death rate from
pneumonia is
in
be
to
the
many
elderly, it is
thoughtthatby concomitant
higher
likely
cardiopulmonary illnesses,
which are more common in the elderly, contribute to
the higher mortality.186-219 However, in some studies,
age itself may be an independent risk factor for death
from CAP.193-213-223-225 In the large meta-analysis
study in which 14 of the cohorts analyzed the
between age and pneumonia mortality,
relationship
the differences in mean
between
>
age
patients who
died and those who survived was 7.8 years.221 Fur
thermore, these investigators performed logistic re
gression analysis on 85 studies that reported the ages
between survivors and nonsurviviors and found that
the odds ratio of dying from pneumonia was 1.05 for
each 10-year increment in mean patient age. Thus,
increased age also has a direct association with
pneumonia mortality. In a prospective study of
> 10,000 persons older than 65 years of age, increas
ing age, diabetes mellitus, congestive heart failure,
and current cigarette smoking were all associated
with a two-fold increase in the risk of death from
pneumonia.226 In addition, both low mini-mental
status exam scores and an inability to perform the
activities of daily living are associated with an in
creased risk of death from pneumonia. In another
study examining the morbidity and mortality from
influenza and pneumonia, congestive heart failure,
COPD, renal insufficiency, diabetes, cancer, and age
all correlated with an increased risk of dying from
pneumonia.227 Radiographic progression of pneumo
nia, more commonly seen in the elderly, is also
associated with increased complications and mortal
ity 194,213
In addition to age itself and associated
cardiopul
1716
disorders, a delayed or missed diagnosis of

pneumonia in elderly patients with atypical presen
monary
tations may
contribute
to
the increased
mortality
rate.186 In a retrospective multicenter cohort study of
elderly patients admitted for CAP, the

quality of care was assessed.228 Based on
state-to-state estimates, the performance of antibiot
ics given within 8 h of admission varied from 50 to
90% and the timely obtaining of blood cultures
(within 24 h) varied from 46 to 83%.228 These
relevant because these two
findings are particularly
if
of
are
associated with a 15 and
care,
met,
processes
10% reduction in the 30-day mortality rate, respec
tively.228 Even in survivors of severe pneumonia,
there is a disproportionately poor functional status in
the elderly, frequently requiring an increased level of
>
14,000
basic
outpatient care.212
Treatment of CAP in the Elderly

For many practitioners, the treatment of CAP has
become largely empiric, based on the patient's med

ical background, age, and exposure. According to the
ATS Guideline (Fig 3), empiric treatment is based
on the probability of having a specific organism in
the setting of the patient's age, presence of comorbid
illness, and severity of pneumonia.229 The Canadian
Consensus Conference (CCC) guideline is similar to
the ATS recommendations, with two notable differ
ences230: (1) the ATS Guideline used a cutoff age of
> 60
years, and the CCC guideline for subgroup
recommendations used a cutoff age of 65 years; and
(2) the ATS approach implied that most patients with
severe pneumonia were in the intensive care unit,
whereas the CCC divided patients with severe pneu
monia into those on the ward and those in the
intensive care unit.231 Because several studies of
severe CAP noted a high prevalence of L pneumophila pneumonia, empiric treatment of very severe
disease should include erythromycin or other mac
rolides in addition to coverage for S pneumoniae and
(3-lactamase ( + ) H influenzae. Depending on the
local antibiotic resistance pattern, penicillin-resistant
S pneumoniae, which is estimated to comprise 22%
of all S pneumoniae strains from 1992 to 1993 (15%
intermediate resistance and 7% high resistance)
should also be considered.232 Penicillin-resistant
pneumococcal infection is more likely to occur in
patients who have recently received a course of
P-lactam antibiotics or who have severe immunosup
pression.233 These guidelines have not been prospec
tively validated, and recommendations should be
weighed
accordingly. A more recent modification of
the ATS Guideline recommends that a combined
with a second- or third-generation cephalo
therapyand
sporin either a macrolide or a fluoroquinolone is
Reviews
Outpatient Treatment
/
60 years with
no co-morbid illness
<
(Macrolide
or
tetracycline
/ \
\
60 years and/or
co-morbid illness
>
Second- or third-
generation cephalosporin
or
inhibitor
p-lac-p-lactamase
or
antipseudomonal
antibiotic
TMP/SMX
+
macrolide
Figure 3. ATS Guideline for empiric treatment of CAP

from ref. 229). ICU intensive care unit; SMX
(adapted
sulfamethoxazole; TMP trimethoprim.
=
their score.222 Elderly patients with NHAP or

influenza have been noted to have fewer respiratory
or systemic signs and fewer complaints such as chills,
cough, and pleuritic chest pain than individuals with
CAP.224-245 An increase in respiratory rate has been
identified as a sensitive indicator of NHAP.206 How
ever, patients simply may present with worsening of
their baseline functional status, such as worsening
anorexia, confusion, or exacerbation of underlying
presenta
cardiopulmonary indisorders. These atypical
tions may result delayed diagnosis and may con
tribute to the high mortality associated with NHAP.
Determining the etiologic agent of NHAP by sputum
examination is fraught with difficulty because of the
perennial question of whether bacteria are coloniz
to
Inpatient Treatment
ing
appropriate for hospitalized immunocompetent

adults with CAP.234 A concise work on toxicity and
the drug interactions of antibiotics in the elderly has

been reviewed.235
For elderly patients with signs and symptoms of
influenza, including those who have been vaccinated,
empiric treatment with amantadine is recommend
ed.236 Furthermore, during epidemics of influenza
A,
especially in nursing homes, chemoprophylaxis
with amantadine or rimantadine, which have been

shown to be effective in preventing influenza A
infection, is recommended for unvaccinated individ
uals, for those who received the vaccine within the
2 weeks, and for immunodeficient per
preceding
sons.237 Unfortunately, neither of these agents are
effective against influenza B.
Nursing Home-Acquired Pneumonia

Nursing home-acquired pneumonia (NHAP)
is
of deaths in institu
also leading
tionalized elderly individuals, associated with up to
50% mortality in bacteremic patients.238-241 Epide
and causative organisms in NHAP are suf
miology different
from CAP and thus will be consid
ficiently
ered separately here. The most likely risk factor for
NHAP is the presence of serious comorbid illnesses
seen with increased frequency in this group of
patients. These conditions may include: (1) underly
ing disorders that suppress immune function (eg,
diabetes, cirrhosis, malignancy, and malnutrition);
(2) increased bacterial colonization of the orophar
ynx, especially with Gram-negative organisms; (3)
such as nasogastric tubes,
therapeutic interventions
neutralization of gastric pH, or recent antibiotic use;
and (4) increased risk of aspiration due to dementia,
stroke, or cognitive effects from medications.242-244
In a prediction rule study that identified low- vs
high-risk
patients with pneumonia, patients with
NHAP automatically received a 10-point surcharge
a
infectious
cause
or
pathogenic.
However,
elderly patients
> 25/low-power field; epithelial cells,

(neutrophils,
< 10/low-power field). As in the case of CAP, blood
cultures and pleural tap if an effusion is present are
recommended. According to the CCC published in
NHAP is
divided
1993, the empiric treatment of
between those patients with nonsevere illness and
those patients that have more severe illness for
whom hospitalization may be required.230 For the
former group, the empiric oral regimen may include
a
second-generation cephalosporin or trimethoprim-
sulfamethoxazole or may include amoxacillin-clavulanic acid with or without a macrolide. For more
severe NHAP, empiric regimens include a fluoroor a second- or thirdquinolone plus penicillin with
or without a macro
generation cephalosporin
lide.
Hospital-Acquired Pneumonia
The incidence of hospital-acquired pneumonia
(HAP) increases significantly with age, and elderly
patients account for a disproportionate number of all
HAf' cases.249-250 In addition, HAP is also the leading
in
chronic care facilities do have increased bacterial

colonization in their oropharynx, a harbinger for
shown that
subsequent pneumonia. Some have
Gram-negative organisms such as Pseudomonas
aeruginosa, Klebsiella pneumoniae, Serratia marc
escens, Acinetobacter calcoaceticus, H influenzae,
and Escherichia coli are the most common etiologic
agents in NHAP,246-248 although Gram-positive bac
teria such as S pneumoniae and S aureus are also
common.140-241 Other organisms to consider in the
nursing home setting include nosocomial influenza,
respiratory syncytial virus, and tuberculosis. Because
of the unreliability of clinical signs and symptoms of
NHAP, obtaining a chest radiograph is especially
important. Empiric antibiotics may be based on
sputum Gram's stain, provided that the sputum is
representative of lower respiratoiy tract secretions
1717
infectious cause of death. However, because HAP is

a clinical diagnosis based on the development of new
infiltrates and on symptoms and signs of a respiratoiy
infection, other disorders such as acute respiratoiy
distress syndrome, congestive heart failure, atelecta
sis, or pulmonaiy infarction may mimic HAP. Con
versely, the absence of sputum in elderly patients
with HAP may result in delayed or misdiagnosis of
infectious pneumonia.215 Risk factors for HAP in the
are essentially the same as those observed in
elderly
NHAP that were outlined above. Age itself may be a
less important risk than the increased frequency of
comorbid conditions and longer hospital stays among
the elderly.251-252 In a study using age-matched
risk factors for HAP include
elderly control subjects,
neuromuscular
nutrition,
disease, and endotra
poor
cheal intubation.250 In addition, contaminated neb
ulized equipment may also be a potential
source.253-254 The increased incidence of Gram-neg
ative bacteria in HAP is undisputed, especially in
patients with critical illnesses. In addition to P
aeruginosa, Enterobacter spp, K pneumoniae, and E
coli, nosocomial S aureus and S pneumoniae should
also be considered.242-255'256 Mixed infections due to
the aspiration of oropharyngeal flora are also com
mon. As in the nursing home, nosocomial respiratoiy
and influenza are sources of HAP,
syncytial virus
in
the
elderly.257 Although a sputum
especially
Gram's stain and a culture should be obtained for the
diagnosis of HAP, difficulties can be encountered
with the interpretation of the results even with
secretions that are suctioned through an endotra
cheal tube. The routine use of more direct sampling,
such as with a protected brush specimen or by BAL,
is still being debated.242
The selection of antibiotics for treatment of HAP
also is based on the concept of "core" pathogens, ie,
organisms that are commonly seen historically and
thus should be empirically covered. Recently, guide
lines for HAP treatment from six different countries
were compared.258 According to the ATS Guidelines
for HAP,259 core pathogens for HAP include Enter
obacteriaceae, S aureus, S pneumoniae, and H influ
enzae. For patients with gross aspiration or for those
who are on high-dose corticosteroids, anaerobes and
Legionella, respectively, also need to be covered.
For patients with severe HAP, P aeruginosa and
Acinetobacter spp also should be treated empirically.
Turerculosis
in the
Elderly
Epidemiology of Tuberculosis in the Elderly

Several important epidemiologic points character
ize tuberculosis (TB) infection in the elderly. First,
the rates for active TB cases are higher in the elderly
1718
than in young adults,260 despite the fact that skin test

reactivity against purified protein derivative (PPD)
decreases with increasing age.261 For example, 53%
of all TB cases are in the 14% of people older than 65
years of age.262 Second, TB case rates are four-fold
higher (234
cases per 100,000 cases in 1985) for

residents of nursing homes than for the elderly living
at home (60 cases per 100,000 cases).263 Third,
although case rates for TB are higher in nursing
home populations than in the community, only 5% of
the population older than 65 years of age live in
nursing homes. Thus, 80% of TB cases among the
elderly occurred in the 95% of the elderly who live at
home.264 High rates of active infection in the elderly
are explained predominantly by a large proportion of
the elderly population having been previously in
fected and subsequently reactivating latent infec
tion.265 Reactivation has been associated with the
development of comorbid conditions that are associ
ated with the waning of cell-mediated immunity,
such as cancer, the use of immunosuppressives, and
aging itself. In addition, those elderly subjects who
have eliminated the tubercle bacilli, and thus have
lost their sensitivity to the tuberculin skin test, are at
risk for reinfection, especially in a closed institution
alized surrounding.266 Mortality rates due to TB are
also highest in the elderly population. From 1979 to
1989, patients who were 65 years of age or older
accounted for 60% of the deaths from TB, a rate that
is 10 times higher than that seen in young and
middle-aged adults.266
Significance of the PPD in the Elderly

In men, PPD reactivity drops from 50% in patients
who are between 65 and 74
of
10% in
years age to
who
are
older
95 years of age; in
than
patients
women, the rate drops from 40% to about 5%,
PPD reactivity in the nursing home is
respectively.261
and
to be due to more than simple
high appears
reactivation of disease.267 Potential explanations for
the high prevalence of positive skin test reactions in
nursing home residents include: the unrecognized
of TB in a closed environment; the early
spread
demise of the anergic patient; an improvement in
nutrition and general health in the patient after
admission; or a delayed or booster effect. In the
nursing home, much evidence suggests that TB is an
important and underrecognized nosocomial infec
tion.263 On admission to a nursing home, the rate of
PPD reactivity (initial test plus booster) is only 10 to
15%. However, higher rates of reactivity are found in
general screenings of nursing home residents, rang

ing from 20 to 51%.267-269 When serial testing is
annual PPD conversion rates are high in
performed,
the nursing home setting. Nearly 5% of 642 nursing
Reviews
home residents converted their skin test over a

1-year period in the absence of an outbreak of
clinical disease.269 Annual conversion rates in 9,937
PPD-negative patients were 5% in homes with rec
ognized infectious cases and were 3.5% in homes
without recognized cases.263 Although the unrecog
nized nosocomial spread of disease is thought to be
the major reason for skin test conversion, investiga
tors in Belgium demonstrated a progressive booster
response with four-stage testing, which supports the
concept that delayed-type hypersensitivity may be
recalled.270 Because of the high rate of conversion in
the absence of symptoms, a two-step skin test is
recommended for residents on admission to the
nursing home: an initial test; and, if the results are
negative or equivocal, a repeat test 1 to 2 weeks later
booster effect is defined as an
(Fig 4). Aof positive
6 mm or more from an induration of
increase
< 10 mm on the first test to 10 mm or more at the
second test. This information at baseline helps to
minimize the spurious appearance of recent trans
mission due to the booster effect and can thus help
to distinguish newly acquired disease from a prior
infection.
two step
tuberculin
skin test
non-reactor-
test yearly or ^
when an active
case is identified
Induration > 10 mm
or
recent converters
Check annually for
chest radiograph
weight loss, fever, cough

INH prophylaxis for
\normal
recent converters or
those with associated

co-morbid conditions
abnormal
(see text)
I sputum for AFB

(-)
treat with at
least 3 drugs
INH prophylaxis for 6-12 months

or if the CXR is suspicious for active TB,
treat with a multidrug regimen
for 4-6 months ("presumptive TB")
Figure 4. Recommended algorithm for the screening of patients

admitted to nursing homes. For the two-step tuberculin skin test,
0.5 U PPD is placed intradermally and, if the induration is < 10
acid-fast bacilli;
mm after 72 h, the test is repeated. AFR
CXR chest radiograph; INH isoniazid.
=
Clinical Presentation of TB in the Elderly

Pulmonary TB is the most common form of TB in
the elderly population. Although the clinical presen
tation of TB in the elderly shares features with the
disease in younger people.cough, weight loss, he
goes
moptysis, and fever.TB in the aged frequently
In one series, adults > 65 years
unrecognized.271-272
of age were significantly less likely to have the
cardinal symptoms of hemoptysis, fever, or night
sweats.273 Differing radiographic patterns of primaiy
infection in the elderly compared to young adults
may lower the suspicion of TB by the health care
In the elderly, midzone and lower zone
provider.274
infiltrates may predominate, in contrast to the upper
lobe pattern of primary TB that is characteristic of
infection in the young adult. Thus, no one lobar
location is classic for the older patient. Miliary TB is
also more common in the elderly person than in the
young adult, although the diagnosis frequently is not
made until autopsy.266-273 Older patients with miliary
TB may present atypically with a protracted illness
that is characterized by absent or low-grade fevers
without localizing signs or symptoms. Other patients
may present with a systemic illness that is character
ized by fevers, weight loss, hepatosplenomegaly, liver
function test abnormalities, and anemia.266-274
Since the clinical presentation of TB in the nursing
home patient may be subtle and the risk of transmis
sion may be high, it is important to suspect TB when
a nursing home patient has a cough or pneumonia
that is not responding to conventional therapy and to

send sputum for an acid-fast smear and a mycobac
terial culture. Perhaps because of the nonspecific
constellation of symptoms, or because of the diffi
culty in expectorating sputum, Patel et al275 report
that geriatric patients are more likely to have a
than are
diagnosis made by fiberoptic bronchoscopy
missed
of
cases
on
with
to
20%
up
younger adults,
but
examination
diagnosed by bronchoscopic
sputum
smear and culture.
Prophylaxis and Treatment

The annual risk of TB in the elderly patient with a
positive PPD is 2 to 3%, but the risk of active disease
for known recent converters is significantly higher
(7.6% for women, 11.7% for men).264-267 Because of
the high rates of active disease for the recent con
verter, isoniazid prophylaxis therapy is recom
mended by many investigators for the elderly nurs
ing home patient who converts a skin test, but
recognizing that there is some risk of isoniazid
toxicity. In 1,935 nursing home residents with risk
factors for TB who were treated with preventive
offered 85% protection against
therapy, isoniazid
infection.276 When isoniazid was given specifically
for skin test conversion, it offered 98.4% protection
and actually improved survival. Only 7 to 12% of this
1719
cohort had drug toxicity (aspartate aminotransferase

level, > 500 U/L) or intolerance.276
In addition to cases of recent PPD conversion,
which is defined as an increase of ^ 15 mm in
induration size for those patients 35 years of age or
older, preventive therapy with isoniazid is also
recommended for the following individuals, re
of age, by the ATS277: (1) a criterion of
gardless
> 5 mm of induration for those
patients infected
with the HIV, for close contacts of an infectious
TB case, and for persons with fibrotic lesions
on a chest radiograph; (2) a criterion of
apparent
> 10 mm of induration for IV
drug users who are
HIV-seronegative and for persons with a variety of
conditions that increase their risk of developing
active disease if infected, including diabetes mel
litus, prolonged treatment with steroids or immu
nosuppressive therapy, Hodgkin's disease or
leukemia, end-stage renal disease, conditions as
sociated with chronic malnutrition including intes
tinal bypass surgeiy, the postgastrectomy state,
chronic peptic ulcers, malabsorption syndromes,
chronic alcoholism, and cancers of the oropharynx
and upper gastrointestinal tract. Generally, 6
months of isoniazid prophylaxis is recommended
for most groups, although in patients with HIV
and silicosis or patients with fibrotic lesions appar
ent on chest radiographs, 12 months of isoniazid
prophylaxis is recommended.277 The risks of iso
niazid prophylaxis include hepatitis, the incidence
of which increases with age, regular alcohol use,
and female gender.278 Persons may develop either
a mild rise in transaminase enzymes, which can
resolve during treatment, or a fulminant lifethreatening hepatitis, and, thus, they should be
screened. Recent experience with rifampin singleagent preventive therapy suggests that this may be
an alternative for persons intolerant to isoniazid or
for those exposed to or infected by an isoniazid-
resistant case.279
Treatment for active TB in geriatric patients is the
same as for all adults.
resistance
TB is presently uncommon in elderly Americans, the
Although multidrug
immigration of people from areas with high rates of
multidrug resistance TB (eg, Southeast Asia and the
Philippines) will likely increase the number of such
cases in the elderly. Treatment regimens for sensi
tive strains include therapy for 2 months with isoni
azid, rifampin, pyrazinamide, and ethambutol, fol
lowed by 4 months of isoniazid and rifampin.
Therapy that is directly observed twice a week has
been advocated as an extremely important measure
to improve compliance with therapy and thus to
avoid the emergence of drug resistance.280
1720
Mycobacteria Other Than TB Infection in the

Elderly
Chronic pulmonary infection due to mycobacteria
other than TB (MOTT), especially Mycobacterium
avium complex (MAC), has received increased rec
ognition in recent years as a significant cause of
morbidity and mortality in the elderly. Although
chronic lung disorders, such as COPD, and prior
bronchiectasis are considered classic risk factors for
chronic pulmonary MAC infections, more recent
investigations have revealed that many patients have
no obvious predisposing factors.281-284 In a retro
spective study of 122 patients with pulmonary MAC
infection who were seen at a referral center between
1965 and 1976, 35% of the patients were > 60 years
old and 7% were > 70 years old.285 More than one
third of the patients had underlying COPD. Treat
ment was more successful in patients who were < 70
years of age, largely because of the poor tolerance in
the elderly to multiple drug combinations.285 Nearly
10 years ago, Prince and colleagues284 described 21
patients with chronic lung infection due to MAC
who had no obvious immunological disorder or no
structural predisposing factor, such as COPD. The
mean ( SD) age of this group of patients was
66.1 9.6 years, and it was composed mostly of
women (17/21 patients [81%]). Although most pa
tients responded to treatment, the relapse rate was
high. Twenty percent of the patients died from
recalcitrant MAC pulmonary infection.284 More re
MOTT infection in
cently, a high rate of pulmonary
the elderly was found in a community practice in
North Carolina.283 In fact, there were more cases of
MOTT infections (20 cases, 19 of whom were HIVthan cases of TB (1 case) diagnosed in this
negative)
suburban practice.283 In the 19 cases of MOTT not
associated with HIV, the mean age was 71 11
years, with the majority of those being women (15/19
patients [79%]) and nonsmokers (89%). Most pa
tients had no predisposing conditions such as COPD,
cancer, prior pneumonia, or treatment with immu
nosuppressive therapy.283 These studies emphasize
that significantly disabling pulmonaiy disease due to
MOTT is not rare in the elderly community.
Sleep Changes
with
Aging
Sleepto patterns
change with normal aging com
the patterns in young adults, and sleep
pared
disturbances are more common for the elderly.
to Dement et al,286 "the strongest and
According
most consistent factor affecting the pattern of sleep
across the night is age," although data to support this
for the oldest elderly, those above age 80, are scant.
At least 20 to 40% of all adults have sleep-related
Reviews
symptoms, the majority of which
are
insomnias.286
Nearly 2 decades ago, Block et al287 noted that of the

30 asymptomatic men studied, two thirds had signif
icant abnormal breathing and oxygen desaturation
abnormali
during sleep; they also noted that these
increasing age and obesity. Re
ported observations of the impact of aging on sleep
include the following. First, self-reports in the el
derly indicate increases with age in the difficulty of
both initiating and maintaining sleep, with more
frequent and early awakenings.288 These disruptions
result in more time in bed, despite less time asleep at
and more napping with increasing age. Sec
night,there
is more variability in sleep duration with
ond,
increased age. Thirty percent of adults sleep < 5 or
> 9 h/night. Persons who are outliers in sleep dura
tion are more common after age 64 and have an
associated increase in mortality,289 although there is
no evidence for causation of death by sleep disor
ders. Third, individuals 50 to 70 years old have
increased sleep latencies, ie, it takes them longer to
get to sleep than younger persons. Fourth, in labo
ratory testing, there is more frequent nocturnal
associated with more sleep fragmentation
awakening
and more stage 1, nonrestorative sleep. There are
more spontaneous nocturnal arousals and a four-fold
increase in time required to return to sleep. Fifth,
the amplitude of slow-wave sleep (stages 3 and 4
restorative sleep) markedly diminishes with age. The
amount of this slow-wave sleep also decreases. Sixth,
there is an age-related reduction in circadian rhythm
such as jet lag or
amplitude such that adjustments
in
shift
work
result
more
rotating
difficulty sleep
ing.290-291 These findings suggest a destabilization of
biological rhythm of the elderly compared to young
adults.
ties correlated with
Significance of Insomnia in the Elderly

Insomnia, the inability to initiate or to sustain
sleep, is common in the elderly, and its cause may be
more difficult to detect than in younger persons.
Numerous medical and psychiatric disorders as well
as commonly used medications may affect sleep
the elderly, leading to fragmented
adversely inThese
include fibromyalgia (increased
sleep.292-293
wave
in sleep), pain, esophageal
intrusion
alpha and
reflux,
neurologic and psychologic conditions
delirium, dementia (decreased rapid eye
including
movement [REM] sleep, increased wakefulness),
depression, anxiety, and Parkinson's disease. Cardio
pulmonary disorders such as heart infailure and
COPD, which have a high prevalence the elderly
population,
may also adversely affect sleep as can the
use of agents such as alcohol, methylxanthines, caf
feine, and hypnotics.294 These adverse effects on
sleep are often amplified in the nursing home, where

residents spend most or all of their time indoors in
levels; in addition, artificial sleeping sched
low-light
ules may be enforced to match nursing shifts.295
Sleep disturbances can lead to an intellectual deficit
even in the nondemented elderly due to daytime
somnolence or to the cumulative insult of hypoxemia
on cerebral function.296
An assessment of insomnia in the elderly should
include evaluation for treatable causes. Hypnotics
should be minimized in the elderly, if used at all,
because these agents have the potential to cause
residual daytime sedation and confusion, rebound
insomnia, withdrawal, respiratory depression, falls,
and the worsening of obstructive sleep apnea
(OSA).297-298 If the major sleep complaints focus on
an inadequate duration of nighttime sleep, the prin
ciples of sleep hygiene, including minimizing time in
bed, performing regular exercise in late afternoon,
and reducing naps, should be discussed, and specific
plans should be tailored for each patient. In a
controlled trial in older, sedentary adults with sleep
complaints, a regular exercise program for 16 weeks
the self-rating of sleep quality.299 If insom
improved
nia is recalcitrant to these maneuvers, other treat
ments could include relaxation training or daily
exposure to bright light at doses of 4,000 lux or
higher. The latter option has been effective in
reducing waking time within sleep and in improving
sleep efficiency.300
Snoring and OSA
Snoring and OSA increase in frequency with age,
especially for men.301 Snoring, the prevalence of
which peaks in the seventh decade, has been associ

ated with an increased risk of stroke.302
Sleep apnea, a major health problem in the elderly
population, may
place
persons at risk for decreased
It
is
estimated
that as much as 95% of
longevity.303
all persons with clinically significant and treatable
OSA remain undiagnosed.290 One study of the el
showed a 31% incidence of OSA in men and a
derly
19% incidence in women.304 This suggests that as
many as 7.5 million elderly Americans may have
sleep apnea. Recently, in a study of > 4,000 men,
who were 20 to 100 years of age, to determine the
relationship of age to apnea, Bixler et al305 showed
that for both central sleep apnea and OSA combined,
the incidence does indeed increase with age. How
ever, when they considered only OSA, the number of
elderly patients dropped (with a peak age of 55
years), a phenomenoninthat is most likely due to a
survival effect. Men, general, are more severely
affected by sleep disordered breathing, but women
are more likely to report or experience mood alterCHEST/114/6/DECEMBER, 1998
1721
Age is a less important risk factor for sleep

apnea, however, than is obesity.306 In addition, when
compared to elderly whites, elderly African Ameri
cans have an increased prevalence and severity of
sleep-disordered
breathing.307 Other acquired con
ditions that may aggravate sleep-related apneas in
clude many disorders seen in the elderly, such as
hypertrophy or lymphoma of the tonsils and ade
noids, acromegaly, myxedema, goiter, micrognathia,
Shy-Drager syndrome, brainstem infarct, brainstem
neoplasm, and encephalitis. Furthermore, the use of
hypnotics and alcohol may exacerbate sleep ap
ations.
nea.298 Stroke may also be more common in persons

with OSA.308
An apnea is defined as a cessation of airflow for
more than 10 s, and a hypopnea is defined as a 50%
reduction in thoracoabdominal movement of at least
10 s duration.309 The number of apneas per hour is
called an apnea index, and an hourly count of both of
these events is called a respiratoiy disturbance index.
older than 65 years of
Twenty-four
percent of people
>
have
an
age
apnea index of 5, which is outside the
normal range for middle-aged adults. A slightly
elevated index in the absence of symptoms failed to
predict morbidity or mortality in the elderly,310
leading to the question of whether the normal range
should be adjusted upward for the elderly, in an
attempt to use the index to diagnose and treat only
clinically significant disease. As presently classified,
the incidence of abnormal respiratoiy disturbance
indexes increases from 3% in the seventh decade to
39% in the ninth decade.311
Signs and symptoms of OSA include heavy snor
ing, choking, excess movements during sleep, and
witnessed apneic episodes. Daytime symptoms in
clude frequent headaches, excessive daytime sleepi
ness, intellectual deterioration, fatigue, personality
and impaired driving ability. Morbidity
changes,
associated with sleep apnea includes systemic and
pulmonary
hypertension, dysrhythmias, and an in
creased risk of myocardial infarction, strokes, sudden
death, and auto accidents.312 Higher apnea indexes
prognosticate lower survival rates. In a study of 385
patients, those with an apnea index of > 20 had a
63% 8-year survival rate compared to a 96% survival
rate if the apnea index was < 20.313
Treatment
is
of OSA
Treatment of OSA likely reduces
particularly
mortality, which
elderly because the
seen with
relevant for the
2.7-fold increase in mortality

OSA may be
even higher for the older person with comorbid
disease.311 Treatment options include assessment for
reversible causes such as nasal obstruction, obesity,
or hypothyroidism before resorting to nasal contin
1722
uous
positive airway pressure (CPAP) or more inva
surgical istreatment modalities. Uvulopalatophanot uniformly effective for patients

ryngoplasty
with OSA, is a less effective treatment than nasal
CPAP, and is likely to be less effective for people
older than 50 years of age.314 Newer modalities, such
as laser-assisted uvulopalatoplasty, have yet to have
adequate outcome assessments.315 In a recent metaanalysis, CPAP
Wright et al316 remind us that the trials that
use or other treatment modalities are
support
uncontrolled and, although the results of their use
show improvements in daytime sleepiness, do not
adequately assess mortality, morbidity, or quality of
life. In addition, most published studies assessed
sive
persons younger than age 65.

Dementia and
Sleep Disorders
Although mild to moderate disturbance of breath

ing during sleep is not associated with cognitive
dysfunction in nondemented elderly subjects, it may
have significant impact in patients with underlying
dementia.317 Sleep disturbances, particularly night
time insomnia and wandering, are common in per
sons with Alzheimer's disease. Slow-wave sleep and
REM sleep both decrease with worsening of the
severity of dementia, resulting in more time awake in
bed, more nocturnal awakening, and more daytime
napping.318-319 Some speculate that the memory loss
in Alzheimer's disease may, in part, result from an
REM sleep deficit or malfunction.320 Abnormalities
of circadian rhythm, for both temperature rhythm
and melatonin secretion, have been seen with in
creased frequency in small series of demented sub
jects compared to normal age-matched control sub
jects.321-322
The disruptive behavior of advanced Alzheimer's
disease has been associated with longer total sleep
times. Disruptive nocturnal behavior is not limited to
dementia from Alzheimer's disease but is actually
more common in Parkinsonism.323 Treatment strat
egies include support and education for family, nap
restriction, and bright-light therapy.324-327 Exposure
to high-intensity light during the daytime may im
prove the sleep-wake cycles for demented persons
who are visually intact, although not everyone has
demonstrated benefits from this treatment.325-328
Benzodiazepines are frequently used but should be
given intermittently and in the lowest possible effec
tive dose.329
Narcolepsy and Periodic Leg Movements of Sleep
Narcolepsy is not more common in the elderly than
in younger adults. In contrast, as many as 25 to 60% of
healthy,
asymptomatic elderly persons may have peri
odic leg movement during sleep,330 the incidence of
Reviews
which rises with age. Periodic leg movement during

as flexion movements or jerking of the
sleep is defined
the night, with at least 5 jerks per hour of
legs during
sleep, each followed by an arousal. It is a potential
cause of disrupted sleep. Treatment options are poorly
defined and include anecdotal claims for success with
odier dopamine agonists, benzodiazopioids, levodopa, and
clonidine,
carbamazepine.331
epines,
Lung Cancer
in the
Elderly
Lung cancer is the leading cause of cancer-related

deaths in the United States, the United Kingdom,
and a number of other countries for both men and
women.332 The overall prognosis for patients with
cancer remains grim, with a 5-year survival rate
lung
of 14%. The incidence of lung cancer is increasing
because of the rise in the aging population coupled
with the fact that lung cancer is primarily a disease of
the elderly, peaking in the eighth decade and due
likely to longer exposure time to tobacco and other
carcinogens.333-335 Smoking is the predominant risk
factor associated with lung cancer; other risks in
clude airflow obstruction, family history of lung
cancer, and respiratoiy exposure to asbestos or radon
gas.332 Treatment of lung cancer in the elderly is a
major area of debate, as clinicians may avoid recom
for an older per
mending curative surgical therapyOne
common misson because of advanced age.336
that
has
important implications for
perception
cancer therapy is that aged individuals have a short
life span. However, it has been estimated that once a
United States reaches the age
healthyherwoman in the
life
of 70,
average
span is another 15 years, and
for a healthy man, another 10 years.337 Another bias
common among physicians is that lung cancer is less
treatable in elderly patients because of comorbid
illness or the inability to withstand the rigors of
surgeiy or chemotherapy. This attitude has trans
lated to less frequent histologic confirmation of
suspicious pulmonary lesions, fewer attempts at cur
ative resection, and fewer recommendations for in
tensive
chemotherapy in elderly patients.334 More
for all types of lung cancer combined,

individuals who are > 65 years of age have a higher
proportion of localized lung cancer when seen ini
tially than that in younger groups.338 The greater
incidence of squamous cell carcinoma and the
smaller incidences of adenocarcinoma and small cell
carcinoma with advancing age may partially explain
the inverse and counterintuitive age-stage relation
cancer.339 Thus, for any given individual,
ship of lung
se
should
not be used as the preeminent
age per
in determining the suitability of
indicator
prognostic
a patient for cancer treatment.340
over,
Non-small cell lung cancer

The median survival for non-small cell lung cancer
(NSCLC) is most closely associated with the perfor
mance status, cell type, and stage of the disease. Age
is generally not considered an independent negative
prognostic indicator in NSCLC,337-340-341 although,
in one large retrospective study, patients who were
< 55 years old at the time of cancer diagnosis had a
greater survival rate than patients > 55 years old.342
However, no comparative analysis was made of
resection rates between the age groups.342 Although
adenocarcinoma is the most common lung cancer
cell carcinoma
histologic subtype overall, insquamous
is the most common type the elderly. This obser
vation may be due to the significantly stronger
association of squamous cell carcinoma with smok
ing.343 Staging strategy recommendations for lung
cancer have been updated recently with an emphasis
on additional diagnostic tests based on symptoms
and abnormal findings on examination.332-344 The
treatment of choice for stage I, stage II, and selected
cases of stage IIIA NSCLC is surgical resection for
patients whose pulmonary reserve can tolerate such
a resection and whose comorbid conditions, espe
cardiac and lung disease, show no
cially underlying
In patients with stages I and II
risk.332
prohibitive
NSCLC that have been treated by surgery, the
5-year survival rate is estimated to> be2.040 to 85%.345
L, or > 60%
Generally, patients with FEVX of
of predicted, have a good physiologic outcome after
pneumonectomy (Fig 5). Although an FEVX of
< 30% of predicted previously precluded surgery,
the increased use of lung-sparing resections, includ
ing sleeve lobectomy, segmentectomy, (thoracoscop
ic) wedge resection, and combined resection with
lung volume reduction surgeiy, has allowed surgical
with less pulmonary
therapy to be inapplied to patients
the past.332 Patients with borderline
reserve than
quantitative
pulmonary function should undergo
scanning to determine their
ventilation-perfusion
candidacy for surgeiy, and those with a predicted
postoperative FEVT of > 800 mL, or > 40% of
can generally tolerate surgery.332
predicted,
More than a decade ago, the overall operative
mortality for surgical resection of lung cancer in
> 2,000 patients was 3.7%.346 Age was an important

risk factor: those < 60 vears old had a death rate of
1.3%; those 60 to 69 years old had a death rate of
4.1%; and those > 70 years old had a death rate of
7.1%.346 In a review of nearly 140 cases of thoracot
omy for lung cancer in which patients were divided
into those < 70 years of age and those > 70 years of
age, as expected, comorbid conditions were more
common in the elderly group and pulmonary func
tion was better in the younger group.347 Although
1723
Uncorrectable PaC02
> 45 mm Hg not due to
Yes.
primary hypoventilation
Contraindication
to pneumonectomy
No
FEV1
>
2.0 L or > 60% of
predicted normal value
Yes.
Acceptable pulmonary
operative risk
Yes.
Acceptable pulmonary
operative risk
tNo
Perfusion
lung scan
Predicted postoperative
FEV1 > 800 ml
or > 40% of normal
No
Unacceptable operative
risk for pneumonectomy
Figure 5. An algorithm to determine the adequacy of pulmonary

function in patients with NSCLC who are candidates for pneu
monectomy (adapted from ref. 332).
the operative mortality rate was higher in the elderly

group, due most likely to coexisting disorders, there
was no difference in postoperative complications,
hospital stays, or actuarial survival among age-strat
ified groups. More recently, in a study of 185 elderly
patients (> 70 years of age) and 472 younger pa
tients with resectable NSCLC, comparable postop
erative complications, operative mortality rates, and
long-term sundval rates were observed.348 In pa
tients > 70 years old, the 5-year survival rate after
surgical resection is estimated to be between 30 and
50%.348,349 xhus, in the algorithm for determining
resection candidates, elderly patients should have
the same criteria as younger individuals,
essentially
and in those with good cardiopulmonary reserve and
functional status, potentially curative pulmonary re
section should not be withheld based solely on
age.350 For elderly patients who are inoperable due
to poor cardiopulmonary reserve, radiotherapy alone
with curative intent have been shown to improve
survival.351 For elderly patients who are inoperable
due to stage IIIB disease, more recent meta-analyses
suggest a small benefit from combined chemother
apy and radiotherapy over radiotherapy alone.352-353
For patients with metastatic disease (stage IV), a
number of meta-analyses have shown a modest
improvement in survival with chemotherapy com
to the best supporting care.354 Although the
pared
survival benefit is often measured in terms of weeks
to a few months, responding patients generally have
improvement in symptoms.
1724
Small Cell Lung Cancer

The relevance of age to prognosis in patients with
small cell lung cancer (SCLC) remains poorly de
fined.334 Some studies have found age to be a
negative prognostic indicator,355-357 while others
have not.358-360 As in NSCLC, stage, treatment, and
performance status are the most important prognos
tic indicators. A small percentage (approximately
8%) of patients with SCLC are candidates for surgi
cal resection.361 Chemotherapy is the cornerstone of
treatment for the majority of cases of SCLC. Be
cause the most frequent site of recurrence after
treatment is the primaiy lesion, combined radiother
apy and chemotherapy is recommended for patients
with limited disease. However, for patients with
extensive disease, adjuvant radiotherapy has not
been shown to further improve survival over chemo
alone but, instead, can increase toxicity.
therapy
There appears to be no significant difference in the
frequency of radiation pneumonitis between patients
older or younger than 70 years of age, although the
pneumonitis may be more severe in older patients,
which, possibly, is a reflection of decreased pulmo
nary reserve and/or coexisting lung disorders in the
The principal issue in SCLC treatment for
elderly.362
an individual is candidacy for chemotherapeutic
treatment. In
some
chemotherapeutic regimens,
greater incidence of bone marrow toxicity has been

noted in the elderly,363 which, possibly, is a reflection
of the diminished bone marrow reserve that accom

panies aging.364 Combination chemotherapy pro
longs survival in extensive stage SCLC, with an
improvement in median survival of a few weeks to a
few months.365 Often the quality of life also improves
with palliative chemotherapy.366 It has been noted
that older patients are significantly less likely to be
offered radiation and/or chemotherapeutic treat
ments than younger patients with the same stage of
disease or even in the presence of similar comorbid
illness.367 In addition, elderly patients are commonly
excluded from clinical trials of chemotherapeutic
agents for SCLC for the reason, real or perceived on
the part of clinicians, that the risk of therapy is too
high, which is similar to the experience in NSCLC
trials. These reasons include decreased bone marrow
reserve in the elderly, increased toxicity from chemotherapeutics, the presence of chronic cardiopul
monary illnesses, diminished life expectancy, and
biases about ag
physicians' own well-intentioned
gressive therapy.337-368 In Southwest Oncology
Group (SWOG) protocols from 1969 through 1982,
elderly
patients were grossly underrepresented for
all cancer types despite the fact that the elderly
patients represent a large segment of the cancer
population.341 For example, in lung cancer, patients

Reviews
older than 70 years of age represented 9% of the

SWOG-enrolled patients, compared to 30% of the
SWOG-excluded population.341
In a study of 24 patients who were older than 70
years of age and who had SCLC, survival was
significantly prolonged with treatment compared to
historical control subjects (median survival of 10
months with a 1-year survival of 30% vs median
survival of 3 to 5 months, respectively).365 These
elderly patients generally tolerated the triple chemo
therapeutic regimen well despite the fact that 58%
had significant but controlled cardiac disease. Less
intensive regimens such as single-agent etoposide or
to lessen toxicity are accompanied by
carboplatin
shorter durations of response, although for complete
survival (13 months) was
responders theto median
that
with
more intensive regi
comparable
In
mens.369-370 a promising study of oral etoposide as
a single agent in elderly patients with SCLC, the
overall response rate was 71% and the median
survival was 16 months for patients with limited
disease and 9 months for patients with extensive
disease.371 Although etoposide may be considered in
the elderly patient who has been deemed unaccept
able for more intensive regimens, more recent stud
ies indicate that older patients should be treated with
the same regimens used for younger individuals, as
the latter protocols are considered more effective in
of
prolonging survival and improving thewith
quality
SCLC
life.372-373 In a study of elderly patients
treated with either cyclophosphamide, doxorubicin,
and vincristine or cisplatin and etoposide, the me
dian survival was 10.7 months for those who received
four or more cycles compared to 1.1 months for
those who received no therapy.374 Others have also
shown that treatment of SCLC in elderly patients
improves survival and quality of life, with the caveat
that modification of the regimen (eg, dose reduc
tion), although necessary to limit toxicity, may make
treatment less effective. There is no additional ben
efit from chemotherapy beyond four to six cycles.
The use of hematopoietic growth factors such as
or granulocyte
granulocyte colony-stimulating factor
factor
may lessen the
macrophage colony-stimulating
concern of bone marrow toxicity in elderly individu
als.375-376
ACKNOWLEDGMENTS: We thank Drs. Charles Irvin, Mi
chael Iseman, Rarry Make, and York Miller for critical reviews of
the manuscript. We are also grateful for the expert illustrative
Leigh Landskroner, Rarry7 Silverstein,

DeSteckelberg, and Martin Kondreck.
assistance of
Nadia
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Respiratory Medicine4

Edward D. Chan, MD; and

(CHEST 1998; 114:1704-1733)

pulmonary function; tuberculosis

American Thoracic Society; CAP com

pathophysiology, diagnosis, and

lung capacity; Vo2max

die United States, the proportion and absolute

increasing.1 It is estimated that by the year 2020,

older than 65 years of age in the United States

From the Division of

Pulmonaiy Sciences and Critical Care

received June 1, 1998; revision accepted June 29,

Assessment of pulmonary function in the elderly is

Changes in the Senescent Lung

because of differences between the tissue types

Changes in the Chest Wall and Muscles

stimulation, is not exactly known.1920 Neither atro

the decrease in diaphragmatic strength.18-2122 This

muscles," and to a lesser extent the inspiratory inter

Changes in Pulmonary Function with Age

Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2013

elderly. The ventilation-perfusion mismatch

Figure 1. Schematic representation of lung volume changes

and by 23 mL/yr in women who are nonsmokers and

Changes In Gas Exchange with Age

The ability to perform physical tasks declines with

dence between the sexes may indicate investigator

likely labeled as having emphysema or bron

Tecumseh, MI, showed that the incidence of asthma

studies have shown

consistent with asthma for years before their

raising the possibility that these patients did not

narrowing is significantly greater in long-standing

Diagnostic Issues of Asthma in the Elderly

the same as that in the younger population, although

("cardiac asthma"), hypersensitivity pneumonitis,

dence between the sexes may indicate investigator

likely labeled as having emphysema or bron

Tecumseh, MI, showed that the incidence of asthma

studies have shown

consistent with asthma for years before their

raising the possibility that these patients did not

narrowing is significantly greater in long-standing

Diagnostic Issues of Asthma in the Elderly

the same as that in the younger population, although

("cardiac asthma"), hypersensitivity pneumonitis,

of both immediate skin testing and IgE levels de

Prognosis of Asthma in the Elderly

respiratory discomfort, concomitant myocardial dys

into perceiving an asthma exacerbation as less severe

mild asthma, and

costeroids for more severe cases. Some investigators

Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2013

response in both age groups was greater with albu

Downloaded From: http://journal.publications.chestnet.org/ on 10/06/2013

relevant in the elderly population,

trolled. To prevent bone loss in patients on chronic

as chronic bronchitis or emphy

elderly. Because COPD is principally a geriatric

view but have focused

Figure 2. Mechanical devices that may aid in the

optimal use of MDIs: (A) accordian-style spacer

immediate drop in carbon monoxide levels.125 Studies