Clinical research study
Respiratory Impairment in Older Persons: When Less Means More

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Abstract

Background

Among older persons, within the clinical context of respiratory symptoms and mobility, evidence suggests that improvements are warranted regarding the current approach for identifying respiratory impairment (ie, a reduction in pulmonary function).

Methods

Among 3583 white participants aged 65 to 80 years (Cardiovascular Health Study), we calculated the prevalence of respiratory impairment using the current spirometric standard from the Global Initiative for Obstructive Lung Disease (GOLD) and an alternative spirometric approach termed ā€œlambda-mu-sigmaā€ (LMS). Results for GOLD- and LMS-defined respiratory impairment were evaluated for their (cross-sectional) association with respiratory symptoms and gait speed, and for the 5-year cumulative incidence probability of mobility disability.

Results

The prevalence of respiratory impairment was 49.7% (1780/3583) when using the GOLD and 23.2% (831/3583) when using LMS. Differences in prevalence were most evident among participants who had no respiratory symptoms, with respiratory impairment classified more often by the GOLD (38.1% [326/855]) than LMS (12.3% [105/855]), as well as among participants who had normal gait speed, with respiratory impairment classified more often by the GOLD (46.4% [1003/2164]) than LMS (19.3% [417/2164]). Conversely, the 5-year cumulative incidence probability of mobility disability for respiratory impairment was higher for LMS than GOLD (0.313 and 0.249 for never-smokers, and 0.352 and 0.289 for ever-smokers, respectively), but was similar for normal spirometry by LMS or GOLD (0.193 and 0.185 for never-smokers, and 0.219 and 0.216 for ever-smokers, respectively).

Conclusions

Among older persons, the LMS approach (vs the GOLD approach) classifies respiratory impairment less frequently in those who are asymptomatic and is more strongly associated with mobility disability.

Section snippets

Study Population

We used data from the Cardiovascular Health Study (CHS) after obtaining institutional review board approval. The CHS is a population-based, longitudinal study of 5888 Americans aged 65 to 100 years, assembled in 1989 and 1990 as a random sample of Medicare beneficiaries.32, 33

For the present study, eligible participants were white and aged 65 to 80 years, and completed at least 2 acceptable spirometric maneuvers at baseline, as defined by the American Thoracic Society (ATS).34, 35 Our analyses

Results

As shown in Table 1, the mean age was 71.5 years and the mean body mass index was 26.3 kg/m2; 57.7% (2066/3583) were female and 55.9% (2002/3583) were ever-smokers. The mean number of chronic conditions was 1.0, and 20.4% (732/3583) had fair-to-poor health status. Respiratory symptoms were reported by 43.6% (1561/3583), and moderate-to-severe dyspnea was reported by 10.2% (365/3583). A slow gait speed was recorded in 38.5% (1378/3583).

Table 2 shows frequency distributions of participants

Discussion

In a representative population of older persons, we found that twice as many participants are given a designation of respiratory impairment using the GOLD versus LMS, with approximately one half versus one quarter of participants, respectively, classified as abnormal. Subsequent analyses revealed that the GOLD results in overdiagnosis according to clinically based assessments. For example, among asymptomatic never-smokers, the GOLD was 4-fold more likely than LMS to assign a ā€œdiseasedā€

Conclusions

Among older persons and on the basis of respiratory symptoms and mobility, respiratory impairment is more clinically meaningful when defined by LMS compared with the GOLD. As 2 potential ā€œless-is-moreā€ benefits of adopting the LMS approach, both the designation of respiratory impairment in asymptomatic individuals and the unnecessary use of medications for (ā€œfalse positiveā€) respiratory disease could be reduced.

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    • Cited by (0)

    Funding: Dr Vaz Fragoso is a recipient of a Career Development Award from the Department of Veterans Affairs and an R03 award from the National Institute on Aging (R03AG037051). Dr Gill is the recipient of a National Institute on Aging Midcareer Investigator Award in Patient-Oriented Research (K24AG021507). Dr Concato is supported by the Department of Veterans Affairs Cooperative Studies Program.

    Conflict of Interest: The study was conducted at the Veterans Affairs Clinical Epidemiology Research Center and the Yale Claude D. Pepper Older Americans Independence Center (P30AG2134). The investigators retained full independence in the conduct of this research. The Cardiovascular Health Study (CHS) was conducted and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the United States in collaboration with the CHS Study Investigators. This manuscript was prepared using a limited access dataset obtained from the NHLBI and does not necessarily reflect the opinions or views of the CHS or the NHLBI.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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