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Determinants of Prognosis of COPD in the Elderly: Mucus Hypersecretion, Infections, Cardiovascular Comorbidity

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Determinants of Prognosis of COPD in the Elderly: Mucus Hypersecretion, Infections, Cardiovascular Comorbidity Copyright #ERS Journals Ltd 2003 Eur Respir J 2003; 21: Suppl. 40, 10s–14s European Respiratory Journal DOI: 10.1183/09031936.03.00403403 ISSN 0904-1850 Printed in UK – all rights reserved Determinants of prognosis of COPD in the elderly: mucus hypersecretion, infections, cardiovascular comorbidity R. Pistelli*, P. Lange#,}, D.L. Millerz Determinants of prognosis of COPD in the elderly: mucus hypersecretion, infections, *Dept of Respiratory Physiology, Catholic cardiovascular comorbidity. R. Pistelli, P. Lange, D.L. Miller. #ERS Journals Ltd 2003. University, Rome, Italy, #Copenhagen City Heart Study, Bispebjerg University Hospital, ABSTRACT: In this paper, the authors update the present knowledge about three risk } factors for the prognosis of chronic obstructive pulmonary disease (COPD), which may Copenhagen, Denmark, Dept of Respiratory Medicine, Hvidovrez University Hospital, be particularly relevant in elderly people: mucus hypersecretion, respiratory infections, Hvidovre, Denmark, Dept of Public Health and cardiovascular comorbidity. Chronic mucus hypersecretion (CMH) is a common Sciences, King9s College, University of London, respiratory symptom in old age, the relevance of which is analysed on the basis of data London, UK. collected during the first three rounds of the Copenhagen City Heart Study. In subjects aged o65 yrs, CMH was a strong predictor of the incidence of respiratory infections Correspondence: R. Pistelli in a 10-yr follow-up period and it was also a strong predictor of death from COPD Dept of Respiratory Physiology (relative risk=2.5). However, CMH was associated with consistently lower forced Catholic University expiratory volume in one second (FEV1) values, but not with an accelerated decline of Via Moscati, 31 00168 Rome FEV1 in this sample of an elderly population. Italy Acute respiratory infections (ARI) are extremely common at all ages, mostly mild Fax: 39 063054641 self-limiting illnesses at a young age, but severe often fatal illnesses in elderly people E-mail: [email protected] already affected by a chronic disease such as COPD. This paper summarises the pre- sent knowledge about aetiology, pathology, prognostic relevance, and prevention of Keywords: Cardiovascular comorbidity ARI. Furthermore, the areas in which further research is needed are listed. Clinical elderly cohort studies clearly support the relevance of cardiovascular comorbidity for the short- mucus hypersecretion and long-term prognosis of elderly subjects affected by severe COPD. respiratory infections In this paper, the recently demonstrated association between particulate air pollu- Received and accepted: April 12 2002 tion and cardiovascular events is reported to suggest the presence of an extremely susceptible cluster of elderly subjects in the population identified by the copresence of chronic obstructive pulmonary disease and cardiovascular comorbidity. Eur Respir J 2003; 21: Suppl. 40, 10s–14s. Chronic mucus hypersecretion In subjects aged w65 yrs, the prevalence was somewhat higher, 13% in females and 18.6% in males. In both sexes, Chronic mucus hypersecretion (CMH), defined as coughing the prevalence was significantly related to smoking (pv0.001). and bringing up sputum forw3 months for at least two consecutive For example, in never-smoking males the prevalence was years, is a common respiratory symptom in elderly persons [1]. 6.7%, whereas in heavy-smoking males it was 23.4%. Pas- In the present analyses, the authors focused on the pre- sive smoking, defined as being a nonsmoker and living with a valence, possible risk factors for, and the prognostic import- smoking spouse, was associated with a significantly higher ance of CMH in a random sample of an elderly population. prevalence of CMH in females (8.8% versus 12.6%; pv0.05), Data were used from the first, second and third examination but not in males (14.6% versus 11.4%). rounds of the Copenhagen City Heart Study, comprising The participants were subdivided into eight groups accord- 3,677 males and females aged w65 yrs, living in the inner city ing to social status, mainly based on their education and type of Copenhagen. The original population sample was drawn of work. In elderly females, there was no relationship between in January 1976 from the Copenhagen Population Register social status and prevalence of CMH, whereas elderly males among a population ofy90,000 inhabitants aged o20 yrs [2]. with low social status had a slightly higher prevalence of The sample was age stratified, with the main emphasis placed CMH (pv0.05). The relatively low impact of social status on the age groups 35–70 yrs. The cohort was investigated for on CMH in this elderly population is in contrast with find- the first time in 1976–1978, for the second time in 1981–1983, ings relating to younger subjects in the Copenhagen City and for the third time in 1991–1994. In general, the response Heart Study [3]. This discrepancy probably reflects cohort rates were y65% in the participants w65 yrs, being highest differences in smoking habits; in the younger age groups, among subjects aged 65–70 yrs (75%) and lowest among those smoking is more prevalent in low social classes, whereas no aged o80 yrs (y32%). social gradient in smoking habits is observed in the elderly sample. In addition, there are probably cohort differences with regard to occupation conditions. Previous exposure to Prevalence of and risk factors for chronic mucus dusts and fumes was significantly (pv0.001) related to higher hypersecretion CMH prevalence: 11.6% in females without exposure versus 28.4% in females with exposure, and in males 15% versus In previous investigations of this cohort, the prevalence of 27.7%. CMH was 8.2% in females and 12.5% in males [3]. There was also a significant association between self-reported MUCUS, INFECTIONS AND CARDIOVASCULAR DISEASES 11s Table 1. – Results from multiple logistic regression predicting lower in both sexes in subjects with CMH, the decline of chronic mucus hypersecretion FEV1 appeared similar in those with and without CMH. These results differ slightly from the authors9 previous obser- Variable OR (95% CI) vation in younger individuals in this cohort, where CMH was significantly related to accelerated FEV1 decline [4]. Male sex 1.1 (0.9–1.3) The importance of CMH as a predictor of survival and Smoking mortality from all causes and respiratory diseases was des- Never 1 cribed using survival analysis. CMH was significantly asso- Previous smoking 1.7 (1.2–2.2) ciated with poor survival. When looking at specific causes of Present smoking 2.8 (2.1–3.8) death using Cox regression models adjusting for age, sex and Multiple chest infections v6 in 10 yrs 1 smoking, it was found that CMH was a significant predictor w6 in 10 yrs 6.2 (4.1–9.2) of death from obstructive lung disease (relative risk (RR)=2.5) Dust and fumes at work 2.2 (1.7–2.7) and lung cancer (RR=2.0). Chest infections in childhood 2.1 (1.6–2.9) It is concluded that in the elderly population, CMH w3 drinks?day-1 1.8 (1.3–2.3) is a very common condition with important prognostic implications. chest infections during childhood and CMH in old age: 12.1% versus 25% in females and 17.1% versus 40.6% in males. In Respiratory infections in the elderly addition, CMH was significantly more common in individuals with repeated chest infections during the 10 yrs before the Acute respiratory infections (ARI) are extremely common CMH assessment. CMH was also more prevalent in individuals at all ages and in all countries. Most are mild, self-limiting with a high consumption of alcohol. illnesses and rarely fatal except in vulnerable groups such as A multiple logistic regression was performed, with CMH as the elderly and where social conditions are poor. Neverthe- the dependent variable and sex, active and passive smoking, less, according to the Global Burden of Disease Study [5], in childhood and recent respiratory infections, industrial dusts 1990 acute lower respiratory tract infections (LRTI) ranked and fumes exposure, alcohol consumption and social status as third among the leading causes of death in the world, most independent variables. The regression showed that smoking, of them (75%) due to illnesses diagnosed as pneumonia. In chest infections in childhood, recent chest infections and contrast to mortality, age-specific incidence rates for ARI alcohol consumption of more than three drinks a day are are similar in most communities regardless of differences in significant predictors of CMH (table 1). geography, and environmental and social conditions. How- ever, the incidence of severe infections, like mortality rates, varies considerably by age and diagnosis. Thus, in persons aged w65 yrs, pneumonia and bronchitis are relatively more Prognostic importance of chronic mucus hypersecretion common than in younger adults [6]. There are several factors that may compromise the validity The prognostic importance of CMH was investigated pros- of statistics on mortality and morbidity. For example, there pectively in different ways. Firstly, the incidence of respira- are no universally agreed clinical criteria for different ARI tory infections during a 10-yr follow-up was studied. The diagnoses. Consequently, there is wide variation in the use distribution of subjects according to presence of CMH and of the same diagnostic label by different practitioners [7]. number of self-reported chest infections is shown in figure 1. Variable access to and use of microbiological laboratories, This confirms that in this elderly population the presence of inadequate reporting systems, under-counting of ARI-related CMH is strongly related to respiratory infections. deaths arising from the application of coding rules that In individuals with repeated measurements of forced accord priority to the "underlying condition", and often expiratory volume in one second (FEV1) during the 15-yr uncertain population denominators, are further complicat- observation period, the relation between lung function and ing factors. On balance, most published statistics probably CMH was investigated.
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