SUPPLEMENT URRENT C OPINION
Chronic obstructive pulmonary disease in the long-term care setting: current practices, challenges, and unmet needs Manuel Suarez-Barcelo a, Joseph L. Micca b, Sharon Clackum c, and Gary T. Ferguson d
Chronic obstructive pulmonary disease (COPD) is a prevalent and disabling disorder in the United States, especially affecting older individuals, women, and those with a history of smoking. Studies show that COPD may be underrepresented, underdiagnosed, and undertreated in elderly patients residing in longterm care (LTC) facilities. The quality of care for LTC residents with COPD is heterogeneous in regard to both the facility and the patient. For LTC facilities, care should be driven by staff education, interstaff communication, and interfacility communication. From the perspective of the LTC patient, choice of medication and device should be based on appropriate diagnosis, comorbidities, ability to perform treatment, and patient preferences. Nebulization is currently underutilized in LTC settings, although it would benefit older patients with low peak inspiratory flow, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. Authors developed a COPD treatment algorithm that focuses on three primary patient aspects to consider when deciding on respiratory device in patients in LTC facilities: inspiratory flow, hand dexterity and coordination, and cognitive capacity. Keywords chronic obstructive pulmonary disease, long-term care, nebulization
INTRODUCTION The term long-term care (LTC) includes a wide variety of facilities/environments designed to care for patients who are no longer able to live independently. These include residential care facilities (RCFs; also referred to as assisted-living facilities/ assisted-living residences), skilled nursing facilities (SNFs)/nursing facilities (also referred to as nursing homes or extended-care facilities), and personalcare homes. In addition, home health agencies (HHAs), hospices, and adult day service providers may assist in providing care in a variety of settings, including private residences. Each service provider cares for a differing population of patients; however, all are faced with the burden of caring for an aging population. Approximately 70% of people older than 65 years need some type of LTC during their lifetime, and more than 40% need care in a nursing home for some period [1]. It is currently estimated that more than 4 million Americans will be admitted to or will reside in nursing homes and SNFs each year [2]. In addition, nearly 1 million people reside in an assisted-living facility. A disease common in LTC settings is chronic obstructive pulmonary disease (COPD), a
heterogeneous disorder constituting persistent respiratory symptoms and airflow limitation, including emphysema and chronic bronchitis [3,4]. COPD develops slowly over years and most often occurs in people aged 40 years and older and those with a history of smoking, although genetic and environmental factors can also lead to disease [5]. COPD causes serious, long-term disability and is exponentially problematic in the LTC population, which consists of older and sicker residents who have increased cognitive impairments, physical impairments, and multimorbidities. This supplement focuses on three key aspects of caring for an aging American population with COPD: current practices in the diagnosis and treatment of COPD in patients a Mt. Sinai Medical Center, Miami Beach, Florida, bPatient Centered Healthcare, Marietta, cRx Answers, LLC, Cumming, Georgia and d Pulmonary Research Institute of Southeast Michigan, Farmington Hills, Michigan, USA
Correspondence to Manuel Suarez-Barcelo, Mt. Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140, USA. E-mail: [email protected] Curr Opin Pulm Med 2017, 23 (Suppl 1):S1–S28 DOI:10.1097/MCP.0000000000000416
1070-5287 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved.
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Respiratory disorders
transitioning to and already in the LTC setting, ways to improve these practices and address current challenges, and the role of nebulized medicine in the LTC setting.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN PATIENTS LIVING IN LONG-TERM CARE Burden of living with chronic obstructive pulmonary disease COPD is the third leading cause of death in the United States, causing roughly one death every 4 min [6]. Age-standardized death rates for COPD have declined 12.7% for men from 1999 to 2014, whereas the rates for women have mostly been consistent across time (Fig. 1) [7]. According to the 2010 National Survey of Residential Care Facilities, the prevalence of COPD was 12.4% in RCFs in the United States [8]. The prevalence in the overall fee-for-service Medicare/Medicaid population enrolled in 2008 was reportedly 18.9%, with a higher prevalence in enrollees aged at least 65 years (21.9%) than in those aged younger than 65 years (14.8%) [9]. In enrollees aged at least 65 years, COPD was most prevalent in those who had a part-year length of stay in an LTC facility (39.1%), followed by full-year LTC stay (25.6%), and no LTC stay (18.6%) [9]. In a study of United States nursing home residents, the overall prevalence of COPD was 21.5% [10]. Although these studies suggest COPD prevalence rates range from
12 to 22% in LTC residents, actual prevalence rates may be much higher because COPD is commonly underdiagnosed or misdiagnosed [11–14]. Patients residing in LTC facilities tend to be of advanced age and often have a number of significant comorbidities (commonly including cognitive and functional deficits). In addition, LTC patients often have multiple diagnoses that are overlooked or suboptimally managed [e.g., asthma, congestive heart failure (CHF)], complicating overall health, well being, and quality of life [9,15–20]. An analysis of a nationally representative sample of older adults (age 67 years) who participated in the Medicare Current Beneficiary Survey (1992–2002) identified that patients with COPD or asthma had generally worse health status than those without COPD or asthma, including more chronic comorbidities, lower self-reported health status, and greater limitations in activities of daily living [21]. The National Survey of Residential Care Facilities reported that less than 3% of RCF residents had no comorbidities, with rates of comorbid arthritis, depression, CHF, diabetes, coronary heart disease, and asthma significantly higher for patients with COPD than for those without COPD (P < 0.05) [8]. In the Health and Retirement Study, cognition scores of older adults (>50 years) with COPD, both severe and nonsevere, were significantly lower than those of adults without COPD (P < 0.001) [18]. In a retrospective analysis of nursing home residents, 68.0% of nursing home residents diagnosed with COPD had a concurrent diagnosis of hypertension, 50.1% had depression, 39.8% had diabetes mellitus, 37.5% had CHF,
FIGURE 1. Chronic obstructive pulmonary disease (COPD) mortality rates in the United States, 1999–2014. COPD as the underlying cause of death was defined by the International Classification of Diseases, Tenth Revision codes J40–J44. Death rates are reported per 100 000 population and were age-standardized to the 2000 US projected population. Source: Reproduced from [7]. S2
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COPD in LTC patients Suarez-Barcelo et al.
37.2% had Alzheimer’s or other dementia, 21.2% had pneumonia, and 8.6% had asthma [10]. In addition, 43.3% of nursing home residents with COPD had moderate or severe impairments in cognitive skills for daily decision making, and 16.2% rarely or only sometimes understood others. Cognitive impairments that LTC residents may present with include communication difficulties, perseveration, aggressive/impulsive behaviors, lack of motivation, memory problems, and wandering [22,23]; these impairments can have significant impacts on the diagnosis, treatment, and maintenance of COPD in older people residing in LTC facilities.
Diagnosis COPD is marked by exacerbations, which are defined as sudden acute worsening of COPD symptoms resulting in additional therapy, with symptoms including dyspnea, chronic cough, sputum production, wheezing, and chest tightness [3,24]. Comorbidities and disabilities of various origins, commonly seen in LTC patients with COPD, can contribute to a reduced recognition of a potential COPD diagnosis and may dominate the clinical scene, with severe exacerbations of COPD presenting atypically and often recognized late [15,25–27]. Advanced age and comorbidities of most LTC patients may make COPD exacerbations more frequent or severe [28–31] and may create challenges with respect to polypharmacy [25]. Whether the comorbidities cause COPD exacerbations, mimic COPD exacerbations, or represent increased COPD severity still needs to be formally investigated. Additionally, cognitive impairment is a common comorbidity in this population and negatively impacts the patient’s ability to bring symptoms to the attention of caregivers. As COPD management is driven by symptomatic presentation, cognitive impairment places the burden of symptom recognition on the caregiver. Lastly, COPD is usually not the primary diagnosis driving hospitalizations in LTC residents, and thus would not be the primary focus of pharmacotherapy and patient monitoring in that setting [32]. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease guidelines [3,4], and reiterated in the American Medical Directors Association (AMDA) COPD Management in the Post-Acute and Long-Term Care Setting guidelines [24], COPD should be considered in any patient with the symptoms of dyspnea, chronic cough, or sputum production, and in any patient with a history of exposure to risk factors; however, guidelines specify that
spirometry is required to establish a diagnosis, with postbronchodilator, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) less than 0.70 as confirmation of the presence of persistent airflow limitation and COPD. The established threshold is independent of reference values, such as age, height, sex, and race. In elderly patients with a diminished lung function (due to age, if nothing else), this threshold may not accurately identify the presence of COPD, and using the lower limit of normal may be more appropriate. The lower limit of normal threshold is based on population reference values and corresponds to the lowest 5% of the normal distribution [3]; however, there is a lack of formal studies evaluating the accuracy of using this method. GOLD guidelines list several key COPD indicators for patients aged older than 40 years that will increase the probability of a diagnosis, including dyspnea that is progressive over time, characteristically worse during exercise and/or persistent; chronic cough that is intermittent and may be unproductive and/or recurrent; any pattern of chronic sputum production; recurrent lower respiratory tract infections; a history of host factors (e.g., genetic factors), tobacco smoke, smoke from home cooking/heating fuels and/or occupational noxious stimuli; a family history of COPD; and/or childhood factors (e.g., low birth weight, childhood respiratory infections). Both GOLD [3] and AMDA [24] guidelines indicate that spirometry is necessary for COPD diagnosis. Although of lesser importance, spirometry may also be of benefit in the assessment of prognosis as well as help with therapeutic decisions and the identification of patients with a rapid decline in lung function. Spirometry informs whether therapy should be pharmacological (e.g., discrepancy between symptomatic grading and spirometric grading) or nonpharmacological (e.g., interventional procedures), as well as if an alternative diagnosis is needed (i.e., symptoms are disproportionate to the degree of airflow limitation). In addition, GOLD guidelines recommend the Chronic Obstructive Pulmonary Disease Assessment Test (CAT) (Appendix A) and The COPD Control Questionnaire as suitable comprehensive assessments of COPD symptoms in clinical practice, whereas more comprehensive health status questionnaires (e.g., the Chronic Respiratory Questionnaire and the St. George’s Respiratory Questionnaire) are too complex for routine practice. Furthermore, the CAT is currently used in the GOLD 2017 ABCD assessment tool for COPD grading and therapeutic recommendations. The modified ABCD groups are now derived exclusively from patient symptoms and exacerbation history, with spirometry separated for diagnosis,
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www.co-pulmonarymedicine.com
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S3
Respiratory disorders
FIGURE 2. The refined ABCD assessment tool (2017). CAT, Chronic Obstructive Pulmonary Disease Assessment Test; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; mMRC Scale, modified Medical Research Council Dyspnea Scale. Source: Reproduced with permission from [4].
prognostication, and consideration of alternative therapeutic approaches (Fig. 2). In summary, there are two grading structures in the updated ABCD assessment tool: spirometric grading for the assessment of airflow limitation (GOLD 1–4; Table 1) and symptomatic grading for the assessment of symptoms and risk of exacerbations (Groups A–D). The GOLD 2017 guidelines separate the assessment of symptoms and exacerbation risk from the assessment of FEV1 predicted, whereas the AMDA 2016 guidelines combine the spirometric and symptomatic gradings, stating that how COPD affects an individual patient is dependent on both Table 1. Stages of chronic obstructive pulmonary disease based on airflow limitation according to AMDA guidelines Grade 1 – Mild Mild airflow limitation (FEV1/FVC
Chronic obstructive pulmonary disease in the long-term care setting: current practices, challenges, and unmet needs Manuel Suarez-Barcelo a, Joseph L. Micca b, Sharon Clackum c, and Gary T. Ferguson d
Chronic obstructive pulmonary disease (COPD) is a prevalent and disabling disorder in the United States, especially affecting older individuals, women, and those with a history of smoking. Studies show that COPD may be underrepresented, underdiagnosed, and undertreated in elderly patients residing in longterm care (LTC) facilities. The quality of care for LTC residents with COPD is heterogeneous in regard to both the facility and the patient. For LTC facilities, care should be driven by staff education, interstaff communication, and interfacility communication. From the perspective of the LTC patient, choice of medication and device should be based on appropriate diagnosis, comorbidities, ability to perform treatment, and patient preferences. Nebulization is currently underutilized in LTC settings, although it would benefit older patients with low peak inspiratory flow, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. Authors developed a COPD treatment algorithm that focuses on three primary patient aspects to consider when deciding on respiratory device in patients in LTC facilities: inspiratory flow, hand dexterity and coordination, and cognitive capacity. Keywords chronic obstructive pulmonary disease, long-term care, nebulization
INTRODUCTION The term long-term care (LTC) includes a wide variety of facilities/environments designed to care for patients who are no longer able to live independently. These include residential care facilities (RCFs; also referred to as assisted-living facilities/ assisted-living residences), skilled nursing facilities (SNFs)/nursing facilities (also referred to as nursing homes or extended-care facilities), and personalcare homes. In addition, home health agencies (HHAs), hospices, and adult day service providers may assist in providing care in a variety of settings, including private residences. Each service provider cares for a differing population of patients; however, all are faced with the burden of caring for an aging population. Approximately 70% of people older than 65 years need some type of LTC during their lifetime, and more than 40% need care in a nursing home for some period [1]. It is currently estimated that more than 4 million Americans will be admitted to or will reside in nursing homes and SNFs each year [2]. In addition, nearly 1 million people reside in an assisted-living facility. A disease common in LTC settings is chronic obstructive pulmonary disease (COPD), a
heterogeneous disorder constituting persistent respiratory symptoms and airflow limitation, including emphysema and chronic bronchitis [3,4]. COPD develops slowly over years and most often occurs in people aged 40 years and older and those with a history of smoking, although genetic and environmental factors can also lead to disease [5]. COPD causes serious, long-term disability and is exponentially problematic in the LTC population, which consists of older and sicker residents who have increased cognitive impairments, physical impairments, and multimorbidities. This supplement focuses on three key aspects of caring for an aging American population with COPD: current practices in the diagnosis and treatment of COPD in patients a Mt. Sinai Medical Center, Miami Beach, Florida, bPatient Centered Healthcare, Marietta, cRx Answers, LLC, Cumming, Georgia and d Pulmonary Research Institute of Southeast Michigan, Farmington Hills, Michigan, USA
Correspondence to Manuel Suarez-Barcelo, Mt. Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140, USA. E-mail: [email protected] Curr Opin Pulm Med 2017, 23 (Suppl 1):S1–S28 DOI:10.1097/MCP.0000000000000416
1070-5287 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved.
www.co-pulmonarymedicine.com
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Respiratory disorders
transitioning to and already in the LTC setting, ways to improve these practices and address current challenges, and the role of nebulized medicine in the LTC setting.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN PATIENTS LIVING IN LONG-TERM CARE Burden of living with chronic obstructive pulmonary disease COPD is the third leading cause of death in the United States, causing roughly one death every 4 min [6]. Age-standardized death rates for COPD have declined 12.7% for men from 1999 to 2014, whereas the rates for women have mostly been consistent across time (Fig. 1) [7]. According to the 2010 National Survey of Residential Care Facilities, the prevalence of COPD was 12.4% in RCFs in the United States [8]. The prevalence in the overall fee-for-service Medicare/Medicaid population enrolled in 2008 was reportedly 18.9%, with a higher prevalence in enrollees aged at least 65 years (21.9%) than in those aged younger than 65 years (14.8%) [9]. In enrollees aged at least 65 years, COPD was most prevalent in those who had a part-year length of stay in an LTC facility (39.1%), followed by full-year LTC stay (25.6%), and no LTC stay (18.6%) [9]. In a study of United States nursing home residents, the overall prevalence of COPD was 21.5% [10]. Although these studies suggest COPD prevalence rates range from
12 to 22% in LTC residents, actual prevalence rates may be much higher because COPD is commonly underdiagnosed or misdiagnosed [11–14]. Patients residing in LTC facilities tend to be of advanced age and often have a number of significant comorbidities (commonly including cognitive and functional deficits). In addition, LTC patients often have multiple diagnoses that are overlooked or suboptimally managed [e.g., asthma, congestive heart failure (CHF)], complicating overall health, well being, and quality of life [9,15–20]. An analysis of a nationally representative sample of older adults (age 67 years) who participated in the Medicare Current Beneficiary Survey (1992–2002) identified that patients with COPD or asthma had generally worse health status than those without COPD or asthma, including more chronic comorbidities, lower self-reported health status, and greater limitations in activities of daily living [21]. The National Survey of Residential Care Facilities reported that less than 3% of RCF residents had no comorbidities, with rates of comorbid arthritis, depression, CHF, diabetes, coronary heart disease, and asthma significantly higher for patients with COPD than for those without COPD (P < 0.05) [8]. In the Health and Retirement Study, cognition scores of older adults (>50 years) with COPD, both severe and nonsevere, were significantly lower than those of adults without COPD (P < 0.001) [18]. In a retrospective analysis of nursing home residents, 68.0% of nursing home residents diagnosed with COPD had a concurrent diagnosis of hypertension, 50.1% had depression, 39.8% had diabetes mellitus, 37.5% had CHF,
FIGURE 1. Chronic obstructive pulmonary disease (COPD) mortality rates in the United States, 1999–2014. COPD as the underlying cause of death was defined by the International Classification of Diseases, Tenth Revision codes J40–J44. Death rates are reported per 100 000 population and were age-standardized to the 2000 US projected population. Source: Reproduced from [7]. S2
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COPD in LTC patients Suarez-Barcelo et al.
37.2% had Alzheimer’s or other dementia, 21.2% had pneumonia, and 8.6% had asthma [10]. In addition, 43.3% of nursing home residents with COPD had moderate or severe impairments in cognitive skills for daily decision making, and 16.2% rarely or only sometimes understood others. Cognitive impairments that LTC residents may present with include communication difficulties, perseveration, aggressive/impulsive behaviors, lack of motivation, memory problems, and wandering [22,23]; these impairments can have significant impacts on the diagnosis, treatment, and maintenance of COPD in older people residing in LTC facilities.
Diagnosis COPD is marked by exacerbations, which are defined as sudden acute worsening of COPD symptoms resulting in additional therapy, with symptoms including dyspnea, chronic cough, sputum production, wheezing, and chest tightness [3,24]. Comorbidities and disabilities of various origins, commonly seen in LTC patients with COPD, can contribute to a reduced recognition of a potential COPD diagnosis and may dominate the clinical scene, with severe exacerbations of COPD presenting atypically and often recognized late [15,25–27]. Advanced age and comorbidities of most LTC patients may make COPD exacerbations more frequent or severe [28–31] and may create challenges with respect to polypharmacy [25]. Whether the comorbidities cause COPD exacerbations, mimic COPD exacerbations, or represent increased COPD severity still needs to be formally investigated. Additionally, cognitive impairment is a common comorbidity in this population and negatively impacts the patient’s ability to bring symptoms to the attention of caregivers. As COPD management is driven by symptomatic presentation, cognitive impairment places the burden of symptom recognition on the caregiver. Lastly, COPD is usually not the primary diagnosis driving hospitalizations in LTC residents, and thus would not be the primary focus of pharmacotherapy and patient monitoring in that setting [32]. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease guidelines [3,4], and reiterated in the American Medical Directors Association (AMDA) COPD Management in the Post-Acute and Long-Term Care Setting guidelines [24], COPD should be considered in any patient with the symptoms of dyspnea, chronic cough, or sputum production, and in any patient with a history of exposure to risk factors; however, guidelines specify that
spirometry is required to establish a diagnosis, with postbronchodilator, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) less than 0.70 as confirmation of the presence of persistent airflow limitation and COPD. The established threshold is independent of reference values, such as age, height, sex, and race. In elderly patients with a diminished lung function (due to age, if nothing else), this threshold may not accurately identify the presence of COPD, and using the lower limit of normal may be more appropriate. The lower limit of normal threshold is based on population reference values and corresponds to the lowest 5% of the normal distribution [3]; however, there is a lack of formal studies evaluating the accuracy of using this method. GOLD guidelines list several key COPD indicators for patients aged older than 40 years that will increase the probability of a diagnosis, including dyspnea that is progressive over time, characteristically worse during exercise and/or persistent; chronic cough that is intermittent and may be unproductive and/or recurrent; any pattern of chronic sputum production; recurrent lower respiratory tract infections; a history of host factors (e.g., genetic factors), tobacco smoke, smoke from home cooking/heating fuels and/or occupational noxious stimuli; a family history of COPD; and/or childhood factors (e.g., low birth weight, childhood respiratory infections). Both GOLD [3] and AMDA [24] guidelines indicate that spirometry is necessary for COPD diagnosis. Although of lesser importance, spirometry may also be of benefit in the assessment of prognosis as well as help with therapeutic decisions and the identification of patients with a rapid decline in lung function. Spirometry informs whether therapy should be pharmacological (e.g., discrepancy between symptomatic grading and spirometric grading) or nonpharmacological (e.g., interventional procedures), as well as if an alternative diagnosis is needed (i.e., symptoms are disproportionate to the degree of airflow limitation). In addition, GOLD guidelines recommend the Chronic Obstructive Pulmonary Disease Assessment Test (CAT) (Appendix A) and The COPD Control Questionnaire as suitable comprehensive assessments of COPD symptoms in clinical practice, whereas more comprehensive health status questionnaires (e.g., the Chronic Respiratory Questionnaire and the St. George’s Respiratory Questionnaire) are too complex for routine practice. Furthermore, the CAT is currently used in the GOLD 2017 ABCD assessment tool for COPD grading and therapeutic recommendations. The modified ABCD groups are now derived exclusively from patient symptoms and exacerbation history, with spirometry separated for diagnosis,
1070-5287 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved.
www.co-pulmonarymedicine.com
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
S3
Respiratory disorders
FIGURE 2. The refined ABCD assessment tool (2017). CAT, Chronic Obstructive Pulmonary Disease Assessment Test; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; mMRC Scale, modified Medical Research Council Dyspnea Scale. Source: Reproduced with permission from [4].
prognostication, and consideration of alternative therapeutic approaches (Fig. 2). In summary, there are two grading structures in the updated ABCD assessment tool: spirometric grading for the assessment of airflow limitation (GOLD 1–4; Table 1) and symptomatic grading for the assessment of symptoms and risk of exacerbations (Groups A–D). The GOLD 2017 guidelines separate the assessment of symptoms and exacerbation risk from the assessment of FEV1 predicted, whereas the AMDA 2016 guidelines combine the spirometric and symptomatic gradings, stating that how COPD affects an individual patient is dependent on both Table 1. Stages of chronic obstructive pulmonary disease based on airflow limitation according to AMDA guidelines Grade 1 – Mild Mild airflow limitation (FEV1/FVC
