Identification and assessment of chronic obstructive pulmonary disease in the elderly.

The early stages of chronic obstructive pulmonary disease (COPD) are silent. This seemingly elusive presentation occurs for many reasons. COPD, which includes the common diagnoses of chronic bronchitis and emphysema, is an indolent process that develops over decades. Fully developed lungs have a tremendous reserve that is not called on during routine daily activities or even with mild exertion. Because the airway obstruction occurs slowly, individuals with early COPD tend to gradually modify their daily lifestyle, decreasing the intensity of their activities to the degree that less lung capacity is needed to routinely function “asymptomatically.” These gradual changes could be even more difficult to perceive in the long-term care environment as a result of the patient’s baseline condition and comorbidities that affect their level of activity. Patients and healthcare providers often do not realize that these modifications have been made because the changes are made over years. Accordingly, a “baseline” for each older patient must be established on an individualized scale. Examining the etiology of COPD can aid in the recognition and differential diagnosis of this disease. More than 90% of COPD is caused by tobacco smoke, with the remainder being attributable to genetic abnormality (ie, alpha-1 antitrypsin deficiency), a history of repeated pulmonary infections and subsequent damage to the lungs, occupational or environmental causes. Individuals who smoke tend to ignore early signs (cough, mucus production, and wheeze) that can warn them of the potential development of COPD. They attribute these symptoms to the habit, accepting that their bothersome cough and clearing of the throat are “part of smoking.” They often do not appreciate that permanent lung damage and chronic airway obstruction can occur. Additionally, the best test to detect COPD during its early silent period, spirometry, is not being used to its full potential in the primary care and long-term care settings. Chronic obstructive pulmonary disease is a major medical and economic problem in the United States. It is the fourth leading cause of death and the only one in the top five that continues to rise (183% in 1965–2000), whereas the other major causes of mortality continue to fall (heart disease, cancer, stroke). COPD accounts for more than 119,000 deaths annually, and the death rate in women with COPD surpassed that in men for the first time in 2000. The death rate has increased threefold more in women than in men since