Pulmonary Rehabilitation Improves Exercise Capacity in Older Elderly Patients with COPD*

Transcription

1 Pulmonary Rehabilitation Improves Exercise Capacity in Older Elderly Patients with COPD* james I. Couser, ]r, MD, FCCP; Richard Guthmann, BA; M. Abdulgany Hamadeh, MD, FCCP; and Cynthia S. Kane, RN, MSN Pulmonary rehabilitation has been shown to improve exercise capacity in patients with COPD. It has been suggested that this improvement applies to all age groups; however, to our knowledge, the effects of pulmonary rehabilitation on older elderly patients (2':75 years of age) have not been studied. We compared changes in 12-min walking distance (12MD) and selfassessment scores in 47 older elderly patients with moderate to severe COPD who completed inpatient or outpatient pulmonary rehabilitation with those achieved by 87 younger patients who participated in the same programs from 1987 to There were 28 older elderly individuals (mean± SEM, 78 ± 1 years) in the outpatient group and 56 younger patients (64 ± 1 years). There were no differences between older and younger outpatients with respect to FEV h FEV IfFVC, maximum inspiratory pressure (Pimax), baseline 12MD, or baseline selfassessment score. After outpatient pulmonary rehabilitation, 12MD and self-assessment scores improved significantly in both groups. Inpatients included 19 older elderly individuals (81 ± 1 years) who were also similar to the 31 younger inpatients (64 ± l years) in FEV h FEV IfFVC, PI max, and baseline self-assessment score, but they tended to be more limited in terms of baseline l2md (p=0.09). After inpatient pulmonary rehabilitation, significant improvements in 12MD and self-assessment were seen in both groups. We conclude that comprehensive outpatient and inpatient pulmonary rehabilitation programs are as beneficial in older elderly patients with COPD as they are in younger patients with similar lung function abnormalities. Patients 75 years of age or older should be considered for comprehensive pulmonary rehabilitation. (Chest 1995; 107:730-34) FEV,= forced expiratory volume in l s; FVC=forced vital capacity; MDI=metered-dose inhaler; Plmax=maximum inspiratory pressure; l2md= 12 min walking distance; PR=pulmonary rehabilitation; Vo2max=maximum oxygen uptake Key words: pulmonary rehabilitation; chronic obstructive pulmonary disease; exercise; elderly pulmonary rehabilitation programs have been shown to reduce dyspnea, increase exercise capacity, reduce hospitalizations, and improve quality of life in patients with COPD.1 6 COPD is a common disease in the elderly and its prevalence is increasing in older age groups. 7 Although most studies of pulmonary rehabilitation in COPD have included older elderly patients greater than 75 years of age, little is known about the relative effects of pulmonary rehabilitation in older and younger patients. Older patients with similar degrees of chronic airflow obstruction may have greater exercise limitations than younger ones due to clinically significant agerelated changes in lung function as well as reduced cardiac function, decreased peripheral muscle strength and endurance, sensory impairment, loss of coordination, and more frequent use of medications.8-10 Although pulmonary rehabilitation is *From the Pulmonary Rehabilitation Program, Rehabilitation Institute of Chicago, the Beuhler Center on Aging, and the Department of Medicine, Northwestern University Medical School, Chicago. Manuscript received February 23, 1994; revision accepted July 11. Reprint requests: Dr. Couser, 6305 Stonefield Road, Middleton, WI thought to be beneficial in all age groups,11-13 to our knowledge, a systematic assessment of its effects in patients 75 years of age or older has not been done. To evaluate the benefits of pulmonary rehabilitation in older elderly patients with COPD, we compared changes in 12-min walking distance (12MD) and self-assessment scores in 47 older elderly patients with COPD who completed comprehensive inpatient or outpatient pulmonary rehabilitation with those achieved by 87 younger patients who participated in the same programs from 1987 to METHODS Records of all patients with COPD who completed the inpatient or outpatient pulmonary rehabilitation program at the Rehabilitation Institute of Chicago from 1987 to 1992 were reviewed. Baseline data were collected that included age, sex, number of prescribed medications, spirometry, and maximum inspiratory pressure (Pimax) on entry into the pulmonary rehabilitation program. Each patient had the clinical diagnosis of COPD, pulmonary function tests consistent with that diagnosis (FEY 1 <70% of predicted and FEY 1/ FYC<70% ), or both. Fifteen patients who completed pulmonary rehabilitation but whose exercise tolerance tests did not conform to standardized l2md were excluded. The outpatient pulmonary rehabilitation program consisted of 1 to 2 weekly 2-h individual sessions for 2 months, whereas the

2 Table!-Characteristics of 84 Patients With COPD Before Outpatient PR* Young (Age <75 yr) (n=56) Men/ women 28/ 28 Age, yr 64±7 No. of rehabilitation sessions 11±3 No. of medications 5±3 FEV,, L 0.92±0.38 FEV,, % predicted 34.0± 13.5 FEVJ/FVC 44.3± 13.1 Plmax, em HzO 43.6±20.0 *Data are expressed as means ± SO. tp<0.01 compared with young patients. Old (Age 2::75 yr) (n=28) 11/ 17 78±3 11±4 5±2 1.02± ±15.2t 50.5± ± 10.8 inpatient program included daily individual sessions for 2 weeks. Patients were admitted to the inpatient program if they had severe exercise limitation or other functional impairment that prohibited participation in the outpatient program. In a few cases, patients entered the inpatient program if difficulties with transportation to and from the medical center precluded outpatient therapies. The exercise component of the programs included both lower and upper extremity training: hall walk, treadmill, stationary bicycle, and repetitive upper extremity exercises with light weights to improve strength and endurance. Training workload was increased based on patient tolerance and was assessed weekly in the outpatients and daily in the inpatients. Outpatients were encouraged to exercise at home between sessions during the program. Other pulmonary rehabilitation program components included the following education sessions related to pulmonary anatomy and pathophysiology, medication and equipment use, nutrition, energy conservation, and stress management; breathing retraining, which included pursed lips breathing and diaphragmatic breathing techniques; bronchial hygiene with chest physiotherapy when appropriate;14 equipment provision and instruction as needed (oxygen, metered-dose inhalers [MDis] spacer devices, and nebulizers); and psychosocial assessment and counseling. On entry into the program, spirometry was performed (Cybermedic Pulmonary Function Testing System, Louisville, Colo) and FEV1. FVC, and FEVJ/FVC were calculated according to the recommendations of the American Thoracic Society.l5 Predicted normal values were taken from Morris et al. 16 Inspiratory muscle strength was measured with Plmax by the method of Black and Hyatt 17 Twelve-minute walk distance was measured before and after pulmonary rehabilitation. It is a simple exercise test that has been used in a number of previous studies as a measure of exercise capacity and functional status18 19 and has been shown to correlate with maximum oxygen uptake (Vozmax) in patients with COPD The 12MD was measured by instructing the patients to try to cover as much distance as possible without severe breathlessness or fatigue in a 12-min period while walking around the perimeter of a large, leveled, rectangular indoor corridor. The number of circuits was converted to feet by multiplying by a constant. Patients performed one practice walk test before the study. No words of encouragement were given during the test. Patient self-assessment was measured before and after pulmonary rehabilitation using a 25-item questionnaire that was developed to determine if pulmonary rehabilitation program participants were receiving and understanding information necessary to cope with their disease. It addressed issues related to dyspnea, self-evaluation of breathing, stress management, and exercise Table 2-Changes in 12MD and Self-Assessment Scores Before and After Outpatient PR Young (Age <75 yr) Old (Age 2::75 yr) 12MD, feet Before PR 1,361 ±658 1,298 ± 791 After PR 1,683 ± 728* 1,800±841 * Increase, feet 322± ±591 %increase Education score, % correct Before PR 73±14 72±16 After PR 93±8* 92±7* *p<o.ool compared with values before PR. patterns. 21 Patients were divided into groups on the basis of age. The younger groups included patients <75 years of age while those in the older groups were 75 years of age or older. The data are presented as mean ± SEM. Statistical analysis included Student's paired two-tailed t tests comparing each subject with himself or herself before and after pulmonary rehabilitation. Comparisons between younger and older groups were made using unpaired t tests. A probability value of <0.05 was considered significant. Statistical computations were performed on a computer (Macintosh LC) using sottware (Statworks). Outpatients RESULTS Baseline patient characteristics are shown in Table l. The younger outpatient group consisted of 28 men and 28 women with a mean age of 64 ± 1 years (range, 48 to 73 years) while the older group included 11 men and 17 women, aged 78 ± 1 years (range, 75 to 85 years). The patients had moderate to severe airflow obstruction and respiratory muscle weakness as shown. There were no differences between groups in number of prescribed medications, number of training sessions, FEV b FEV IfFVC, Plmax, baseline 12MD, or self-assessment score. The older patients had a higher FEV 1 expressed as percent of predicted. Twelve-minute walking distance increased significantly after pulmonary rehabilitation in both outpatient groups as shown in Table 2. The younger patients improved 24% from 1,361±88. feet to 1,683 ± 97 feet while the older patients went hom 1,298 ± 150 to 1,800 ± 159 feet, a 39% increase (Fig 1). There were no significant differences in 12MD before or after pulmonary rehabilitation between the two groups. After pulmonary rehabilitation, patients in both outpatient groups performed better on the educational self-assessment questionnaire (Table 2). In addition, most patients in both groups reported subjective improvement in dyspnea and their ability to perform activities of daily living. Inpatients There were 31 young inpatients, 11 men and 20 women, aged 64± 1 years (range, 48 to 74 years), and CHEST / 107/3/ MARCH,

3 Q 1000 :J1 N 500 Before PR Ed After PR Before 2000 Ed After PR E' :E N PR ** 0 Outpt < 75 Outpt ~ 75 Inpt < 75 lnpt ~ FIGURE l. Changes in 12MD before and after PR. There were significant increases in 12MD after pulmonary rehabilitation in all groups (p<o.ool). 19 older inpatients, 7 men and 12 women, aged 81 ± 1 years (range, 76 to 95 years). Abnormalities in lung function and inspiratory muscle strength in the inpatients paralleled those seen in the outpatients as shown in Table 3. There were no significant differences between inpatient groups with respect to number of medications used, number of sessions, FEV 1. FEV 1 expressed as percent predicted, FEV d FVC, or Plmax. Inpatients had more severe exercise limitation than outpatients at baseline and the older inpatients had a tendency toward lower baseline 12MD than younger inpatients (p=0.09). After inpatient pulmonary rehabilitation, 12MD improved significantly in both groups (Table 4). Younger patients went from 581 ± 111 feet to 931 ± 135 feet, a 60% increase, while older elderly patients increased 127% from 295 ± 107 feet to 669 ± 146 feet (Fig 1). Self-assessment scores improved after inpatient pulmonary rehabilitation in both groups (Table 4). Figure 2 shows that when outpatients and inpatients were combined and grouped according to age, there was significant improvement in 12MD in all age Table 3-Characteristics of 50 Patients With COPD Before Inpatient PR 75 Young Old (Age <75 yr) (Age 2:::75 yr) (n=31) (n=19) Men/ women 11 / 20 7/ 12 Age, yr 64 ± 7 81±5 No. of rehabilitation sessions 11±4 10±3 No. of m edications 7±4 9± 3 FE V1, L 0.81 ± ±0.28 FEV J, % predicted 31.9 ± ± 12.0 FEVJ/FVC 51.1± ±10.8 Plmax, em H ± ± < ~ 8 5 FIGUI\E 2. Changes in 12MD before and after PR according to age g roup. Astensk=p<0.05; dagger=p<o.ol; double dagger= p<o.ool ; double asterisk= p=0.08. groups except for the five oldest elderly patients who were greater than 85 years of age. Their 12MD improved, however, the increase did not reach statistical significance, probably because of the small number of patients in this group (p=0.08). DISCUSSIO N It has been suggested that the benefits of pulmonary rehabilitation apply to all age groups, but little is known about the relative merits of such programs in patients older than 75 years of age, a rapidly growing segment of our population. Our data suggest that comprehensive outpatient and inpatient pulmonary rehabilitation programs are as beneficial in older elderly patients with COPD as they are in younger ones with similar lung function abnormalities and exercise limitation. Older elderly individuals are appropriate candidates and should be considered for comprehensive pulmonary rehabilitation. COPD, a common problem in the elderly, is often underdiagnosed and undertreated While pulmonary rehabilitation has become an accepted component in the management of many individuals with Table 4-Changes in I2MD and Self-Assessment Scores Before and After Inpatient PR Young Old (Age <75 yr) (Age 2:::75 yr) 12MD, feet Before PR 581 ± ±465 After PR 93.1 ± 751 * 669±638* Increase, feet 350± ±427 % increase Education score, % correct Before PR 70 ± ±16 After PR 92 ±8* 89±10* *p<0.001 compared with values before PR. 732

4 COPD,25 26 there is still controversy about which patients are most likely to benefit.27 Some pulmonary rehabilitation studies have excluded patients older than 70 years The rationale for age exclusion was not given in these studies; however, all three also excluded patients with other disabling conditions, including arthritis, ischemic heart disease, and heart failure. Older elderly patients may have been considered inappropriate for pulmonary rehabilitation because it was believed that they were "too old," that they would not tolerate aggressive treatment,31 or that the physiologic effects of aging and comorbid illness would limit their ability to improve exercise capacity. There are a number of reasons why the older elderly may be particularly good candidates for multidisciplinary pulmonary rehabilitation. They frequently have greater difficulty with metered-dose inhaler (MDI) technique32 33 and they are more likely to have adverse drug reactions than younger patients34 and so may benefit from extensive education and training about appropriate medication, MDI, and spacer use. Some authors have suggested that the older elderly may be more limited than younger patients due to more frequent use of medication,9 but this was not the case in our study. Older elderly persons are more likely to have coexistent cardiac and musculoskeletal diseases, sensory impairment, and reduced cognitive function than younger individuals, 10 so supervised and monitored physical therapy and exercise training may be especially beneficial in the elderly. In this study, older elderly inpatients were the most severely limited in terms of exercise capacity, even though their lung function impairments were similar to those seen in younger inpatients. This finding suggests that exercise limitation in the older patients was not due to pulmonary dysfunction alone and that coexistent disorders may have contributed to reduced exercise capacity. The proportional improvement in the older elderly inpatient group was also greatest. Although the mechanisms of benefit are unclear, a multidisciplinary program such as ours may be particularly appropriate for older, more broadly disabled individuals in order for them to maintain independence and self -sufficiency. Studies on changes in exercise capacity in patients with COPD after pulmonary rehabilitation have included individuals >75 years of age, but the average patient age is usually between 50 and 67 years Corriveau and coworkers36 compared the effects of inpatient pulmonary rehabilitation in patients aged 60 years or younger with those seen in patients older than 60 years. They found that both groups of patients were able to increase exercise levels and Vo2max after rehabilitation and that there was no relationship between age and change in Vo2max. The mean age in their "older" group was 64 ± 1 years. O'Donnell and colleagues37 recently reported that an outpatient exercise training program led to significant reduction in breathlessness and increases in exercise capacity in 23 elderly patients with COPD when compared with age-matched controls who did not participate in exercise training. The mean age of their elderly patients was 66 years. Our data suggest that these benefits can be extended to very elderly patients with mean age approaching 80 years. Performance of 12MD depends on several factors, including endurance, respiratory function, cardiovascular fitness, and neuromuscular function Cardiac and neuromuscular dysfunction may have contributed to exercise limitation in this study but were not quantitated on entry into the pulmonary rehabilitation program. Also, motivation, encouragement, and practice may affect the 12MD It is possible that a learning effect contributed to improvement in our patients, but there is no reason to think that such a learning effect would occur preferentially in older elderly individuals. The benefits achieved by our patients after pulmonary rehabilitation are similar those seen in other recent studies. N eiderman and coworkers5 showed a 26% increase in 12MD (from 1,349 to 1,700 feet) after outpatient pulmonary rehabilitation in 33 patients with a mean age of 66 years and mean FEV 1 of 1.2 L. In our study, 84 outpatients with a mean age of 68 years and mean FEV 1 of 0.96 L increased their 12MD by 29%, from 1,340 to 1,722 feet. Foster and Thomas39 observed a 98% increase in the 6-min walk test after inpatient pulmonary rehabilitation in a group of 317 patients with COPD with a mean age of 67 years and mean FEV 1 of 0.65 L. Our 50 inpatients with a mean age of 70 years and mean FEV 1 of 0.79 L increased their 12MD by 76%, from 472 to 831 feet. The major limitation of this study is that it is retrospective. Quantitative data related to baseline cardiovascular and neuromuscular function and to changes in dyspnea, activities of daily living, quality of life, and cost-benefit after pulmonary rehabilitation in the older elderly were not available. Prospective studies should be done to evaluate these and other outcomes of pulmonary rehabilitation in elderly patients with COPD.40 In summary, this study suggests that comprehensive pulmonary rehabilitation is beneficial in older elderly patients with COPD. These patients are appropriate candidates for pulmonary rehabilitation programs and should not be excluded on the basis of age alone. Increased understanding of their disease and improved exercise capacity are likely to enhance functional status and quality of life in these individ- CHEST 1107 / 3 1 MARCH,

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