The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Andrew McIvor MD, MSc, FRCP, Professor of Medicine, McMaster University; Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, ON.

At present, some 750,000 Canadians are known to have chronic obstructive pulmonary disease (COPD). This number is believed to represent the tip of the iceberg, as COPD is often only diagnosed in the advanced stage. Respiratory symptoms or a previous smoking history are common among older adults yet they seldom trigger further assessment for COPD. Objective demonstration of airflow obstruction by spirometry is a simple procedure, even in older adults, and is the gold standard for diagnosis of COPD. Early intervention with routine nonpharmacological management includes partnering with the patient and family, providing education, smoking cessation, vaccination, collaborative self-management, and advice on exercise and pulmonary rehabilitation. Anticholinergic inhalers remain the gold standard for optimal bronchodilation and dyspnea relief in COPD, and new long-acting agents have underpinned new treatment algorithms, improving quality of life and exercise capacity as well as reducing exacerbations. For those with advanced disease, recent trials have reported further benefits with the addition of combination inhalers (inhaled corticosteroid and long-acting B2-agonist) to core anticholinergic treatment. Physicians and patients can expect a promising future for COPD treatment as significant advances in management and improved outcomes in COPD are now being made.
Key words: chronic obstructive pulmonary disease, older adults, spirometry, diagnosis, management.

Max Huang, MD, FRCPC, Respirology Fellow, Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON.
Lianne G. Singer, MD, FRCPC, Medical Director, Toronto Lung Transplant Program, University Health Network; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Chronic obstructive pulmonary disease (COPD) often has a profound effect upon the quality of life and mortality of the older adult. Despite numerous medical treatments, surgery may be considered for the symptomatic patient with medically-optimized, end-stage COPD. Bullectomy, lung volume reduction surgery (LVRS), and lung transplantation have all proven to be important surgical therapies. This article reviews the current state of these interventions, and the criteria when deciding on the best surgical option for a given patient.

Key words: emphysema, COPD, lung transplant, lung volume reduction surgery, bullectomy.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Jean Bourbeau MD, MSc, FRCPC, Montreal Chest Institute of the Royal Victoria Hospital, McGill University Health Centre; Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology and Biostatistics, McGill University, Montreal, QC.

With the population progressively aging, the geriatric aspects of COPD deserve special consideration. Older adults with respiratory symptoms and a current or previous history of smoking should be considered for a diagnosis of COPD. Objective demonstration of airflow obstruction is mandatory for the diagnosis of COPD. The majority of older people can adequately perform spirometry for an objective demonstration of airflow obstruction. Nonpharmacological treatment includes smoking cessation, vaccination, self-management education and communication with a case manager, and pulmonary rehabilitation. Bronchodilators are the most important agents in the pharmacotherapy of COPD. Inhaled corticosteroids are indicated for patients with recurrent exacerbations who are already on optimal bronchodilator therapy.

Key words: chronic obstructive pulmonary disease, older adults, diagnosis, spirometry, management.

George P. Chandy, MD, MSc, Department of Medicine, University of Ottawa, Ottawa, ON.
Shawn D. Aaron, MD, MSc, Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, ON.

Chronic Obstructive Pulmonary Disease (COPD) has been increasing in prevalence over the past several decades. The impact of COPD on the health status of Canadians will continue to be a major issue, despite declining rates of smoking, as physiologic manifestations of COPD may only be evident decades after the initiation of smoking. Given the delay between the initiation of smoking and the development of significant disease, COPD is primarily a disease of the older population. While a cure for COPD is not available, a number of medications have been noted to have a significant impact on symptoms, exercise tolerance, and quality of life.

Key words: COPD, treatment, management, older adults.

The Lung Association Helps Patients Learn to Manage COPD

Susan Lightstone, co-author of Every Breath I Take: A Guide to Living with COPD, and former Senior Advisor for the National Judicial Institute, Ottawa, ON.

Looking hopeful and gazing skyward, Lorraine LeBlanc is pictured on the front cover of The BreathWorks Plan, a 41-page educational guide about living with Chronic Obstructive Pulmonary Disease (COPD) written for those, like Ms. LeBlanc, who know they have the disease or those who suspect they might have it. The guide is plainly written and full of practical advice for COPD patients on how to work together with their doctors to manage their disease, and is also intended for use by the family, friends and caregivers of those with COPD.

The BreathWorks Plan is distributed free of charge and forms an integral part of The Lung Association's recently announced BreathWorks Program.

Dr. Robert Hyland, MD, FRCPC, Physician-in-Chief, St. Michael's Hospital, Professor of Medicine, University of Toronto, Toronto, ON.

Introduction
Before considering the impact of chronic obstructive pulmonary disease (COPD) in the elderly, the normal physiological changes that take place in the lungs with aging should be reviewed¹ (Table 1). In general terms, the lungs lose elastic recoil properties and alveolar surface area. This results in a mild decline in expiratory flow rates, and an increase in trapped air (residual volume) along with a decrease in resting arterial partial pressure of oxygen (PaO2). Airway closure occurs progressively in dependent portions of the lung in the supine position beginning in the mid-40s, and the sitting position in the mid-60s. This airway obstruction results in some shunting and further hypoxemia. Muscle strength--particularly diaphragmatic--declines and the chest wall becomes stiffer, contributing to decreased exercise tolerance. Neural reflexes to hypoxia and hypercapnia as well as the perception of changes in lung stiffness and air flow obstruction are blunted in elderly patients, decreasing their awareness of acute problems. Despite all these changes, it is probably fair to say that lung aging is not limiting unless affected by disease. However, elderly patients also have a less effective cough, are prone to aspiration and have less effective lung defenses, thereby increasing the risk of infection.

D'Arcy Little, MD, CCFP
York Community Services,
Toronto, and
Department of Family Medicine
Sunnybrook Campus of
Sunnybrook and Women's
College Health Sciences Centre,
Toronto, Ontario

Chronic Obstructive Pulmonary Disease (COPD) is a general term for a group of conditions characterized by some or all of the following features: a chronic cough, increased sputum production, shortness of breath, airflow obstruction, and impaired gas exchange. Unlike asthma, which is usually episodic and reversible, the major characteristics of COPD are that it is chronically progressive and irreversible. Under the umbrella of COPD, there are two major disease categories: chronic bronchitis and emphysema. Chronic bronchitis is clinically characterized by a productive cough, lasting three months of the year for at least two consecutive years. Pathologically, chronic bronchitis is characterized by mucus gland and airway smooth muscle hypertrophy. Emphysema is clinically characterized by dyspnea, although the other features mentioned above may also be present in various degrees. Technically, emphysema is a pathological diagnosis characterized by destruction of the air spaces distal to the terminal bronchioles (respiratory bronchioles, alveolar ducts and alveoli). It is worthwhile to note that it may not be clinically important, or useful, to categorize a patient as having either chronic bronchitis or emphysema.