Accurate diagnosis of chronic respiratory diseases in older patients can help them live fuller, more productive lives.
Our nation’s population is growing older. By the year 2025, the number of individuals reaching the age of 80 will be double what it was in 1990.1 Technology and health care have improved the life expectancy despite the fact that many still have unhealthy lifestyles. The result is a population that will live longer, but must learn to live and manage chronic diseases in order to remain independent. It is estimated that 14 million persons in the United States suffer from chronic obstructive pulmonary disease (COPD) with an increase of 41.5% since 1982.2 These patients pose a challenge to respiratory therapists as they help plan care that will manage symptoms, prevent complications, and preserve independence in these individuals as long as possible.
As we age, the factors that impact our ability to remain healthy and functional become more complex. Respiratory therapists working with older adults need to understand how these factors impact their patients in order to monitor for complications and plan interventions that are effective. Once individuals have a chronic respiratory disorder, the emphasis changes from prevention and cure to helping individuals preserve as normal a life as possible. Limiting our assessments to the physical system will result in care that is incomplete. Elderly patients often have more than one chronic condition, and the physical, social, and mental status of older individuals is closely related to their ability to manage day-to-day activities despite their impairments or disabilities.3 If we do not understand the whole picture, we do a disservice to our patients.
Patient assessment, as reviewed in this article, is the use of clinical judgment (based on education and experience) coupled with the use of assessment instruments to gather information used to evaluate the patient’s health status, and to plan interventions and referrals for care. The extent of an assessment is determined by the health care professional’s involvement in planning care. Respiratory therapists in the acute care setting, responsible for the delivery of a specific therapy, may limit their assessment to determining the patient’s response to therapy and detecting any complications as a result of therapy or disease. If respiratory therapists are responsible for the discharge planning of patients, they will have to expand their assessment to include those factors that may affect the patients’ ability to comply with prescribed care, and manage daily life when they leave the acute care facility. Assessment may be performed by one person, or it may be a combined effort of a multidisciplinary team. No matter what the case is, all persons involved must understand the interrelationships between each area of assessment and the impact on the overall plan of care.
The purpose of this article is to look at factors that affect health and function in older adults and those with chronic respiratory diseases. This information is geared to provide insight on how to make a more complete assessment of those older patients with respiratory diseases in order to make an impact on their ability to live and cope with their disease. As we age, we encounter physiological changes. Many people find it is more difficult to perform the day-to-day activities we may now take for granted. Those with chronic illness have additional problems related to their disease(s) that may make independence and activities of daily living an even greater challenge.
Impact on the Effects of Aging
We all experience physiological changes as we age. We can adapt to some changes and others we can slow by adopting healthier lifestyles. The ability to stay independent in the home is related to the ability to remain physically and mentally functional so that we can manage the day-to-day tasks of living. Once disability or impairment occurs, the tasks or the environment must be modified. If modifications are not possible, it may mean relying on others for care. Those who are not fortunate enough to have family members close by or the financial means to pay for assistance may have to be placed in long-term care.
I am firmly convinced that the secret to leading a long and productive life is to keep moving, despite disease or impairment. Many older adults often become more sedentary. Decreased activity can be a result of limitations caused by the physiological or psychological effects of chronic disease, or the assumptions that reduced endurance and weakness are inevitable results of aging. Patients with chronic respiratory diseases may decrease activity as a result of increased dyspnea. Lack of activity can lead to weaknesses that become harder to reverse, compromising patients’ ability to take care of themselves. Simple tasks requiring the use of the upper extremities, such as combing hair and shaving, become difficult for patients with respiratory diseases. Signs of poor hygiene may be a clue that patients cannot perform daily grooming. Teaching patients breathing techniques, having them wear their oxygen equipment while performing difficult tasks, or taking their treatments beforehand can be simple interventions that can help decrease symptoms associated with these tasks. Patients with chronic respiratory diseases are at higher risk at an earlier age for reduced mobility and function. Identifying problems is essential to establishing effective interventions. Several tools for evaluating activities of daily living are available. The most common tool is the Katz Activity of Daily Living Scale. A list of common scales and when to use them is included in Table 1 (page 84). If deficiencies are identified, respiratory therapists can help patients identify various ways to perform tasks more efficiently or ask their physicians to refer them to a pulmonary rehabilitation program. A man with COPD once told me that the best advice I had ever given him was to have him take a deep breath and exhale with pursed lips while he bent down to put on his socks.
| Tool | Purpose | Population | Time | Reference |
| Katz Index of ADL | Descriptive ADL | Gerontology | 1 | |
| Barthel Index | Descriptive -ADL, ,IDL | Adult Rehabilitation | 1 hour | 2 |
| Beck Depression Scale | Evaluative | Adults | 10 min | 3 |
| Zung Self-Administered Depression Scale | Evaluative – Self-admin | Adults | 5 min | 4 |
| Geriatric Depression Scale | Evaluative | Adults – older | 15 min | 5 |
| Mini-Mental Exam | Evaluative | Adults | 10 min | 6 |
| Short Portable Mental Status Questionnaire | Evaluative | Adults | 10 min | 7 |
| 1. Katz S, et al. Studies of illness in the aged. The Index of ADL: a standardized measure of biological and psychosocial function. JAMA Vol. 185:914-919. 2. Mahoney FJ, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65. 3. Depression Guideline Panel. Depression in Primary Care. Vol 1: Detection and Diagnosis. Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services; 1993. AHCPR publication 93-0550. 4. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63-70. 5. Brink T. Development and validation of geriatric depression scale. J Psychiatr Res. 1983;17:37-49. 6. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189. 7. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Geriatr Soc. Vol. 23:433-441. |
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| Table 1. Common tools for evaluating daily living activities. | ||||
Fractures, especially of the hip, can often result in loss of independence for older adults because of prolonged hospitalization if complications arise. Osteoporosis is a result of aging, and inactivity can increase the risk of fracture due to a fall. The risk of osteoporosis in COPD or chronic asthma patients is also increased because of the use of steroids to treat their disease. Each year, thousands of older adults become disabled after falls.4 They can be prevented by recognizing those at risk, making necessary changes in the environment, and implementing strategies to increase activity. Older adults who continue to exercise and use weight training will not experience the loss of strength and endurance affecting those who lead more sedentary lives.5 COPD patients who participate in pulmonary rehabilitation programs have been shown to improve physically and psychologically even though lung function remains unchanged.6
Aging also results in changes in vision and hearing. Changes in sight can impact older patients’ ability to read, and this needs to be considered when choosing or creating patient education materials. Chronic respiratory patients are at higher risk for cataracts if they have had to use oral or inhaled steroids for many years. To correct for loss of vision or hearing, the therapist might notice that a patient moves closer while speaking. This should be a clue that a referral for further evaluation should be considered since many visual or hearing impairments can be treated. I remember one specific patient with chronic asthma who was visiting the emergency department (ED) more often despite his ability to take breathing treatments at home. He lived in an assisted living complex that had once been a college dormitory. While visiting at his apartment, I found that the only light in the small room was a wall-mounted, fluorescent fixture that did not give off much light. The patient suffered from cataracts, and because of the low light in his apartment, he could not see to put the medicine in the nebulizer cup. Therefore, he did not take his treatments very often. We found a table lamp that gave off better light and he was able to take his treatments at home and the ED visits ceased.
Individuals with chronic respiratory disease may also experience other chronic diseases such as diabetes, hypertension, coronary artery disease, or congestive heart failure (CHF). Assessment of patients with multiple disorders can become very challenging. For patients with COPD and CHF, it is sometimes difficult to determine if a change in respiratory status is due to an exacerbation of the COPD or an increase in fluid from the CHF. Table 2 shows common chronic diseases, how treatment or pathophysiology impacts patients with respiratory diseases, and how to assess for changes or complications in these conditions. It is important for respiratory therapists to expand their knowledge base and assessment skills if they are to continue to gain responsibility for care of patients with chronic respiratory disorders.
| Chronic Disease | Impact on Resp, Dx (Tx or DX) | Common Signs | Complications | Assessment Tools (Basic) |
| Hypertension | Beta blockers-exacerbate symptoms ACE inhibitors—can cause cough |
Systolic > 140 mm Hg Diastolic > 90 mm Hg |
Renal disease Stroke Cardiac dysfunction Problems from medication |
Serial blood pressures BUN, creatinine LOC, vision, neurologica |
| Diabetes | Steroids used in Resp. Dx Increase BS | Fasting BS > 12 6 mg/dl** HbA1C > 6% Thirst Weight loss Frequent urination |
Coronary artery disease Neuropathy Microvascular disease Renal disease Retinopathy Wound problems: esp feet Decreased healing |
Glucose levels HbA1C Bun, creatinine Foot exams weekly |
| Congestive heart failure | Increased fluid can exacerbate dyspnea | Peripheral edema Dyspnea Increased JVD S3 heart sounds |
Pulmonary edema Pulmonary effusion Electrolyte disturbances Digoxin toxicity |
Physical exam for signs Daily weight training |
| * National Institutes of Health, The Fifth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure: 1993. ** American Diabetes Association Report of the Expert Committee on the Diagnosis and Classification of Diabetes. Diabetes Care. 1997. |
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| Table 2. Common chronic diseases and assessment tools for changes and complications. | ||||
Nutrition
It is estimated that 25% of COPD patients experience malnutrition.6,7 Increased work of breathing results in higher caloric demand by the respiratory muscles, but patients often experience a decline in appetite as a result of shortness of breath. The imbalance can result in weight loss and malnutrition. Loss of muscle mass can occur if protein requirements are not met. Without adequate nutrition, there can be loss of mobility due to weakness and increased risk of infectious diseases, such as pneumonia. It is important to inquire about patients’ daily eating habits. Weight loss is the most obvious clue and should be reported to their physician as soon as possible since it can often signal the beginning of a rapid decline. Other factors that can affect nutrition in the elderly are poor-fitting dentures or loss of teeth, decreased mobility, medication side effects, financial constraints, loneliness, or depression. Patients with COPD should be given information on good eating habits and those with obvious deficiencies should be carefully evaluated and referred to a nutritional counselor.
Evaluating Mental Function and Mood Disturbances
The ability of persons to care for themselves is greatly influenced by their mental and emotional well-being.3 More than 1.5 million persons are affected by some form of dementia and this number is expected to double by 2020.8 Dementia is a cognitive disorder that affects memory, orientation, and the ability to concentrate and can arise from a number of organic problems. It is not considered to be a normal part of aging, but the incidence increases with age. In patients with chronic respiratory disease, hypoxemia, and hypercapnia, there are two possible causes of reversible dementia. In older patients it is important to view all sudden changes in mental status as potentially reversible, and to look for causes such as infection, electrolyte or blood gas imbalances, as well as adverse effects from medication. Aging also results in a decrease in renal and liver function. Many medications are metabolized by the liver and/or excreted by the kidneys. This means that medication may remain in the body for a much longer time, resulting in increases in side effects, complications, and medication interactions. Many people are turning to alternative therapies such as herbal remedies. This type of therapy is not well studied and has various physiological effects and medication interactions. Evaluation of sudden changes in mental status should always include a thorough investigation into all medications (including over-the-counter and herbal preparations), and any recent changes made by either the physician or patient.
Mental deficiencies can result in impaired judgement and decision-making, and can result in serious injury. The most common and easiest tool to use is the Mini-Mental State Examination. This examination is composed of 12 verbal or written tasks that evaluate cognitive impairment. It is easy to use and has been shown to be valid even when those administering it have minimal training. Table 1 (page 84) lists several commonly used tools for assessing mental status. Included are resources for the tools and the populations where validity has been established. Respiratory therapists working with chronic respiratory patients may be the primary health care professionals these patients are in contact with. Identifying changes in mental status and referring patients back to their physicians for further evaluation can prevent complications and possible injury.
It is estimated that between 5% and 25% of older Americans living in the community suffer from some psychiatric disorder9 with an estimated incidence of depression as high as 15%.10 Depression has also been found to be common in patients with COPD. This is often a result of having to cope with the physiological and psychosocial changes associated with chronic illness.11 COPD patients often quit their jobs earlier than planned due to their disability. This may mean changes in financial status and in roles they play in their family or community. These changes can be very hard to accept. The reality of having a chronic disease is that it can not be cured. Patients must learn to cope with changes to their routines and responsibilities, and accept that these changes are probably permanent. Depression can result in decreased motivation and has been shown to exacerbate symptoms such as shortness of breath and pain.3 Patients who are depressed experience more hospitalizations and are more likely to become dependent on others for their care. Screening tests can identify depression and referrals can be made for counseling and treatment. Patients are often reluctant to admit that they may be depressed because of the stigma that some give to this diagnosis. Respiratory therapists may also be reluctant to bring up such a sensitive subject and may not feel qualified to handle emotional problems. Depression scales are valid instruments that can be administered by asking a few questions. When I suspect that patients are depressed and they are giving clear signals that they do not wish to discuss it, I have given them a Beck Depression Scale to take with them. This scale is easy to answer and score. If it shows they may be depressed, they can take it to their primary care physician. There are other scales that are easy to administer and are made specifically for older adults. Table 1 gives several resources that can be used.
Individuals with chronic respiratory disease must learn to manage symptoms that accompany their disorder so they can live life to the fullest. It is important for all health care professionals to evaluate the many factors that impact the patients’ ability to control their disease and remain functional and independent as long as possible. They will need to consider the impact of aging as well as the disease(s) that are present when assessing older patients for care. Older individuals, in general, have complex needs and are entering an era in their lives when they have less resources. Individuals with one or more chronic disease(s) face more obstacles to overcome each day. Pulmonary rehabilitation programs have long recognized the importance of addressing psychosocial and nutritional issues as well as the obvious issues of treatment and disease when working with COPD patients. It is time that all respiratory therapists consider these areas when they are assessing chronic respiratory patients and planning care no matter what the setting.
Mari Jones, MSN, FNP, RRT, is a nurse practitioner and respiratory therapist at Mid-South Pulmonary Specialists, Memphis, Tenn.
References
1. Administration on Aging. Growth of the 65+ population, by age group: 1990-2050. Available at: http://www.aoa.dhhs
gov/aoa/ststs/growthchart97.gif. Accessed October 9, 1999.
2. American Thoracic Society. Definitions, epidemiology, pathophysiology, diagnosis, and staging. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;152:S78-S83.
3. Emlet CA. Assessing disturbances in mood, thought and memory. In: Emlet CA, Crabtree JL, Condon VA, Treml LA, eds. In-Home Assessment of Older Adults. Gaithersburg, Md: Aspen Publishers; 1996:50-51, 180-196.
4. National Institute on Aging. Age Page: Preventing Falls and Fractures; 1992.
5. Bahr R. Musculoskelatal system. In: Burggraf V, Stanley M, eds. Nursing the Elderly—A Care Plan Approach. Philadelphia: Lippincott; 1989:150-181.
6. American Thoracic Society. Comprehensive outpatient management of COPD. Am J Resp Crit Care Med. 1995;152:S84-S96.
7. American Thoracic Society. Additional considerations. Am J Resp Crit Care Med. 1995;152:S111-S113.
8. Crooks T. Dementia. In: Carstensen LL, Edelstein BA, eds. Handbook of Gerontology. New York: Pergamon; 1987:96-111.
9. Hooyman NR, Kiyak HA. Social Gerontology. 3rd ed. Needham Height, Mass: Allyn & Bacon; 1993.
10. National Institutes of Health. Diagnosis and Treatment of Depression Late in Life. Bethesda, Md: Author; 1991.
11. American Thoracic Society. Comprehensive outpatient management of COPD. Am J Resp Crit Care Med. 1995;152:S84-S96.
