Chronic obstructive lung disease is a major cause of disability and death all over the world. Similarly in India, it is recognized as a major health problem requiring management from the primary health care (1). Asthma is one of the most common chronic diseases all over the world. For the last 30 years, there has been a rise in asthma prevalence; 10-12% in adults, whereas in children it is 15%. It appears to be stabilizing in developed countries. In developing countries, there is a rising incidence, which is associated with urbanization (2).

Asthma can appear at any age, but usually, a peak is seen in the 3 years age group. Long-term studies that have kept children under follow up upto 40 years of age suggest that many with asthma become asymptomatic during adolescence but asthma returns in some during adult life; particularly in those with persistent symptoms and severe asthma (3).

Asthma is a heterogeneous disease. It is the hyper-responsiveness of the airway tracts. It is usually triggered by various stimuli, like dust, pollen, and other environmental factors. It is associated with a specific chronic inflammation of the mucosa of lower airways (4).    It is difficult to differentiate asthma from chronic obstructive pulmonary diseases, as both diseases present with similar symptoms in the elderly. Characteristic symptoms with which a patient presents are dyspnea, wheeze and cough. Pulmonary function tests help in the confirmation of the disease. Simple spirometry confirms airflow limitations with a reduced FEV1, FEV1/FVC ratio, and PEF. Reversibility is demonstrated by a >12% and a 200ml increase in FEV1 15 minutes after an inhaled short-acting β2 agonist (5).

According to GINA guidelines asthma COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. ACOS is therefore identified in clinical practice by features that it shares with both asthma and COPD. Post-bronchodilator increase in FEV1 >12% and 400ml from baseline is compatible with a diagnosis of ACOS (6). The main drugs for COPD can be divided into bronchodilators, which give rapid relief of symptoms mainly through relaxation of airway smooth muscle, and controllers, which inhibit the underlying inflammatory process(7).

Exacerbations of COPD are feared by patients and may be life threatening. One of the main aims of controller therapy is to prevent exacerbations. In this respect, Inhaled Cortico Steroid (ICS) Therapy and combination inhalers are very effective. However, limited literature is available on the effective use of ICS in older people. The older people may be limited functionally and cognitively in understanding the use of ICS and may make mistakes in the use of ICS whereas functionally and cognitively fit elderly may be able to use ICS like any other younger adult(8). Hence we presume that asthma in the elderly is poorly controlled .In view of this, there is a need for the study on clinical profile of asthma in the elderly with special reference to functionally and cognitively impaired elderly and their ability to use ICS therapy.

The study was conducted on patients with OLD attending Pulmonary Medicine or General Medicine over a period of 1 year from May 2023 to April 2024. Patients who were clinically stable and on inhaled corticosteroids were also included in this study. Patient’s functional and cognitive impairment was assessed by Barthel's index and Montreal Cognitive Assessment.

A total of 100 patients over 60 years of age and 30 below 60 years were studied. All the 130 patients affected with OLD were recruited consecutively as outpatients during their regular checkup visits and inpatients in General Medicine and Pulmonary Medicine ward at Mamata Academy of Medical Sciences hospital on meeting the inclusion criteria.

After the ethical clearance, informed participants or their relatives was interviewed for symptoms of dyspnea, cough, wheeze, chest pain, drowsiness, altered sensorium. A detailed clinical examination was done with reference to respiratory rate, the pattern of breathing, chest expansion, anteroposterior & transverse diameter, percussion note and auscultation findings, the functional status was noted using Barthel’s index (9) and cognitive impairment status was noted, using Telugu or Hindi MoCA (10).

Investigations which were done for each patient included complete blood count, erythrocyte sedimentation rate, chest x-ray, oxygen saturation & pulmonary function tests with spirometry. Each patient was asked to complete the following four questionnaires’, Barthel’s index, the Montreal cognitive assessment, Medical research council dyspnea scale and Cough severity index.

Dyspnea was graded by MRC dyspnea scale. (11)

• Grade I- Not troubled by breathlessness except on strenuous exercise
• Grade II- short of breath when hurrying or walking up a slight hill
• Grade III- Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
• Grade IV- Stops for breath after about 100 m or after a few minutes on the level
• Grade V- Too breathless to leave the house or breathless when dressing or undressing

Degree of cough was assessed by the cough severity index questionnaire (12) and was scored as follows:

• 0= Never.
• 1= Almost never
• 2=Sometimes.
• 3= Almost always.
• 4= Always

The Barthel’s index was based upon an ordinal scale that evaluates feeding, bathing, grooming, dressing, bladder control, toileting, and chair to bed transfer, mobility and climbing stairs. Subjects were classified by a score ranging from 0 (complete dependence) to 20 (complete independence). The Montreal cognitive assessment was administered for screening cognitive impairment. It includes visuospatial/executive, naming, memory, 

In the present study, out of 130 patients with OLD, 100 were in the age group of >60 years with a mean (SD) age of 67.3(5.66) years, and 30 were in the age group of <60 years with a mean (±SD) age of 42.16(8.82) years. Of those patients 96 (73.8%) were male, and 34 (26.1%) were female. Clinical profile of the studied population showed, almost all patients presented with dyspnea, and cough. Severities of those were assessed by MRC grading and cough severity index score respectively.

Table1: Comparison Of Severity of Dyspnea in The Study Population:

Severity of dyspnea in this study, showed that 71(55.9%) out of 127 patients with dyspnea had grade-III, 41 out of 127 had grade-II dyspnea, 10 out of 127 had grade IV dyspnea, and 5 out of 127 had grade I dyspnea (Table 1).

Graph 1: Comparison Of Severity Of Dyspnea In The Study Population.

Table 2: Comparision of Cough Severity in The Study Population.

Table 2 presents, cough was observed in 127 out of 130 study population, with varying severity. Severity of cough was assessed by cough severity index score. 11 out of 127 patients had CSIS of 1, 55 out of 127 patients had CSIS of 2, 43 out of 127 patients had a CSIS of 3, and 18 out of 127 patients had CSIS of 4. Median CSIS observed in the study population was 2 (i, e cough effects the activities of daily living sometimes).

TABLE 3: GROUP STATISTICS.

Of the 130-study population, median of respiratory rate was 24 cycles/minute. Mean (SD) BMI in the study population among males of < 60 years age was 23.26(3.56), females in the same age group was 23.98 (6.53), where as among males of >60 years it was 22.98 (4.25), and in females of >60 years it was 23.77(3.03).  Mean (SD) oxygen saturation in the study population among males of < 60 years age was 93(3)%, females in the same age group was 94 (4), whereas among males of  >60 years it was 91 (3), and in females of >60 years it was 92(3). Mean (SD) FET observed in the study population among males of < 60 years age was 5.3(2) seconds, females in the same age group was 4.6 (2) seconds, whereas among males of  >60 years it was 5 (2) seconds, and in females of >60 years it was 4.9 (2.4) seconds (Table 3).

Table 4: Use Of Different Modes of Inhalers in The Study Population:

Figure 2: Use Of Inhaler Therapy In The Study Population.

Different prescriptions of the study population was observed and found out that 107 out of 130 were on different modes of inhalers (i,e rota halers, metered-dose inhaler, and nebulisations). Of 107 patients on inhaler therapy, 79.4% (85) were using rotacaps, 10.3% (11) were using MDI, 5.6% (6) were using both rotacaps & MDI, and 4.7 %( 5) were using nebulisations at home (Figure 2 and table 4).

Figure 3: Inhalational Technique Observed In The Study Population

Figure 3 shows effective use of inhalers was assessed by the inhalational score. Out of 107 patients on inhaler therapy in the study population, 9(8.4%) patients had an inhalational score of 10, 8(7.47%) patients had an inhalational score of 9. 57(53.2%) patients had an inhalational score of 8, 15(14.02%) patients had an inhalational score of 7, and the remaining 18 (16.9%) had an inhalational score of 6.

Table 5: Distribution Of Cognitive Impairment Levels In The Study Population

Of the 130 patients, cognitive Impairment was seen in 88 (67.9%) of the study subjects.

Table 6: Spearman Correlation of Clinical Variables with Cognitive Impairment

Correlation of Functional and Cognitive impairment was checked with recurrent attacks, Inhalation Scores, Eosinophil count, ESR, Neutrophil count, Total counts, SpO2, Respiratory rate and MRC Grade to determine correlation. Inhalational score, Eosinophil and Neutrophil counts had significant correlations with MoCA Score. Lower inhalation scores were significantly present with lower MoCA scores while eosinophil and neutrophil counts were higher. (Table 6).

Table 7: Correlation Of Physiological And Inflammatory Markers With Cognitive Impairment

After Regression analysis, Inhalation score (p<0.001) and Eosinophil count (p=0.018) were found to be significant predicted by MoCA outcome; while SpO2 (p=0.004), Inhalation score (p=0.006), Neutrophil count (p=0.001) and Eosinophil count (p=0.003) were significant for Barthel Score. All other variables were not significantly correlated with cognitive impairment SpO­2, Inhalational score, Eosinophil and Neutrophil counts had significant correlations with Barthel Score. Lower SpO2 and inhalation scores were significantly seen in those with lower Barthel scores; while eosinophil and neutrophil counts were higher. All other variables were not significantly correlated with functional impairment

In our cross-sectional study, we evaluated a total of 130 patients with OLD of which 100 patients are in the age group more than 60 years and 30 patients in the age group of less than 60 years, presenting to a tertiary care hospital in Mangaluru. In our study primary objective was study of clinical presentation, to compare pattern of prescription and to assess the efficacy of inhalational technique in geriatric population with OLD. The secondary objective includes the functional and cognitive impairment in OLD in the elderly and to correlate clinical profile and inhalation scores.

The demographic information related to the patients was noted, a comprehensive history and physical examination was conducted, and relevant laboratory investigations were performed. In this study, 130 patients with OLD, are already diagnosed, or are confirmed with spirometry, clinical features of the patients revealed that most of the patients were presented with dyspnea of MRC grade III (55.3%), and cough with a median cough severity index score of  2 ( 46.07% ), use of accessory muscles during respiration was noted in 76 of 130 patients (67.07%), rhonchi was noted in 110 of 130 patients( 84.3%). 107 of 130 patients ( 82.3% ) were on different modes of inhalers, of which only 9 (8.2% ) knows correct inhalation technique.     

In a study conducted by S C Allen and S Ragab,  states  that there is a relation between ability to learn inhaler technique to cognitive status and tests of praxis in old age. a study done on 30 inpatients on rehabilitation ward, shows that there is a correlation between inhalation score to ideomotor dyspraxia and inhalation score to a mini-mental test score. This study also shows that elderly patients, who are unable to use an MDI despite the normal mental status score, have some evidence of cognitive impairment. Similarly in our study, lower inhalational scores have significant correlation with cognitive impairment which is statistically significant (p = <0.0001).

In a study conducted by S Peruzza et al. on- the effect of COPD on the functional status and quality of life, had taken spirometry, 6MWD, MRC dyspnea score and Barthel's index into considerations and underweight (BMI <18.5), IHD, severe liver and kidney diseases and acute disease conditions were excluded. Based upon which they suggest that degree of impairment; functional status and physical activity in the elderly affect the severity of chronic airway obstruction. In another study conducted by Vasileios Andrianopoulos et.al (14), states that in an OLD patient cognitive impairment are a prevalent limitation, therefore cognitive deficits should be considered before planning the management of OLD. Similarly in our study, lower inhalational scores had the significant correlation with the functional impairment which is statistically significant (p = 0.004) and recurrent attacks of OLD.

In our study, Inhalation score (p<0.001) and Eosinophil count (p=0.018) were found to be statistically significant predicted by MoCA outcome; while SpO2 (p=0.004), Inhalation score (p=0.006), Neutrophil count (p=0.001) and Eosinophil count (p=0.003) were statistically significant for Barthel Score.

In a systematic review conducted by Barbara S, Kritikos V, Bosnic-Anticerich S, identified 14 comparitive studies addressing the differences in numbers or types of errors in elderly and younger patients with asthma and COPD. This review states that, there is some evidence which shows, as with increasing age, there were increasing proportions of incorrect inhaler therapy users- which is based on the incidence of improper inhalation technique. It was also noted that the memory deficits and declined executive planning which were seen in the elderly, further contribute to the decrease in ability to perform proper inhalational technique in the elderly population. They had taken into consideration a study done by Allen & Prior, which states that only adults with full cognitive functions can execute the proper technique. Based on the findings of this review, it is indicated that there are many functional and cognitive issues among elderly population which potentially increasing the risks of inhaler technique. The statistical analysis of our study correlates with the findings of this systematic review.

LIMITATIONS:

1. Lack of socioeconomic profiles.
2. Selection bias, as most of the patients who were included in the study were admitted in the hospital, were poorly controlled which may be because of disease severity rather than poor compliance of therapy.
3. Study population were not followed up. All patients were evaluated at a one time visit or during their admission.

From our study we noted that patients who were receiving inhaler therapy for maintenance of OLD were not aware of proper inhalational techniques. This could not only affect the disease process but also their quality of life. This might result in worsening of dyspnoea and inappropriate stepping up of the therapy. These patients may also show significant cognitive impairment. Thus it is advisable to spend time with the patients in out-patient visits to assess the inhalational technique and also do cognitive assessment. Large scale studies are required with frequent and longer duration of follow ups to assess the improvement in cognitive parameters.

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