Comprehensive COPD programs: The growing imperative

Chronic obstructive pulmonary disease (COPD) is a challenging lung illness that requires continual adjustment in lifestyle, and often results in an increased loss of independence due to physical restrictions and shortness of breath. Understanding and caring are critical for helping individuals with COPD, as is the ability to recognize, diagnose and treat the disease on a daily basis and throughout its progression.

COPD encompasses emphysema, chronic bronchitis, irreversible asthma and severe bronchiectasis. The two main causes of COPD are cigarette smoking and Alpha-1 antitrypsin (AAT) deficiency. Air pollution and occupational dusts can also contribute to COPD, especially when the person exposed to these substances is a cigarette smoker.

While the death rate from heart disease and stroke are declining in the U.S., the death rate from COPD is on the rise. According to a recent study, one in six admissions to nursing homes was for individuals who had a history of emphysema or COPD. This puts greater pressure on LTC facilities to gain a stronger understanding of the disease and to meet new demands in terms of assessment and treatment. Toward this end, it’s critical that directors or managers of such facilities take steps to put a comprehensive COPD program into place.

The level of COPD knowledge this program would entail goes beyond traditional health education, requiring official guidelines for diagnosis and treatment of COPD, research updates, access to resources for individuals and their families and professional educational credit-earning opportunities. Outcomes from implementing effective guidelines include:

• Earlier detection
• Better symptom control
• Increased patient function in activities of daily living and participation in social activities
• Decreased anxiety and depression caused by shortness of breath and other COPD symptoms
• Improved use of oxygen therapy and COPD medications, resulting in improved resource utilization and decreased care costs
• Reduction in rates of viral and bacterial infections
• Reduction in the frequency of hospital transfers because of acute exacerbations
• Better understanding of when and how to initiate palliative care

In order to maximize these outcomes, it’s important to make an assessment and establish a baseline for each individual who may be at risk for COPD.

ASSESSMENT

In LTC facilities, individuals with COPD fall into one of the following categories:

• Primary
• Secondary 
• Unrecognized presence of COPD, with symptoms developing in the facility
• End-stage  

To screen newly admitted individuals for COPD and its risk factors, it’s important to ask the individual and family members about a history of lung disease or other signs and symptoms that may indicate COPD and look for any of these indicators:  

• Dyspnea that is progressive, persistent and worsens with exercise
• Chronic cough that may be intermittent and/or unproductive
• Chronic sputum production
• History of exposure to tobacco smoke, occupational dusts and chemicals

Typically, classifications of the disease—mild, moderate, severe or very severe—indicate necessary treatment.  

TREATMENT

Treatment for COPD in seniors can be challenging due to their poor vision and impaired mental and memory functions. Healthcare providers in a community setting need to be able to recognize the signs of acute COPD and know what interventions will lead to successful self-management based on the individual’s condition and abilities.

Costs associated with exacerbations are high, particularly due to relapses of bronchial infection. Optimizing treatment for COPD helps to reduce exacerbations and includes rehabilitation, self-management plans and physical activity, all of which can improve breathing and physical endurance. Furthermore, effective management of COPD can prevent additional lung damage.

Treatment should take into account the needs of each individual, including comorbidities, prognosis, life expectancy and preferences, especially in terms of advance care directives. In addition, it’s important that education, nutrition and exercise be tailored to each individual. Those who smoke should be encouraged to stop smoking and be given access to counseling for smoking cessation and nicotine replacement therapy. Annual flu and pneumonia vaccine are advised for all individuals with COPD.

STAFF TRAINING

With proper training, nurses should be better able to understand current medical treatments and how to provide a higher care level for residents with COPD, including the ability to:

• assess the individual’s capability for using inhalers, with the understanding that patients who self-administer rescue inhaler therapy should be re-assessed periodically and their refills monitored for overuse
• administer inhaled medications for individuals who can’t do it for themselves
• recognize acute change of condition in an individual with COPD, including any change in baseline dyspnea, cough, sputum or mental state so that it can be reported to a supervising nurse

COPD is a progressive disorder, so individuals must be reassessed on a regular basis—as often as four times a year or when a significant change in the individual’s condition occurs. LTC providers, as well as individuals and their families, should understand, however, that COPD is not a hopeless condition. With better education, training and disease management, staff can enable individuals with COPD to increase their quality of life and bring greater peace of mind to family members.

John W. Walsh, who was diagnosed with Alpha-1-related genetic COPD in 1989, is the Co-Founder and President of the COPD Foundation, a not-for-profit organization dedicated to developing and supporting programs, which improve the quality of life through research, education, early diagnosis and enhanced therapy for persons whose lives are impacted by Chronic Obstructive Pulmonary Disease (COPD). He is also the Co-Founder of the Alpha-1 Foundation (a research organization) and AlphaNet, Inc. (a not-for-profit disease management services company run by and for patients). He can be reached at jwwalsh@copdfoundation.org.