Geriatric Pulmonology: Challenges and Updates

Respiratory illnesses are a leading cause of morbidity and mortality among older adults, often complicated by age-related anatomical, physiological, and immunological changes. As global populations age, pulmonary diseases in older adults pose increasing public health challenges. India, as a result of a transitional demographic phase, has witnessed a rise in the geriatric population from 1991 to 2001. It is projected to be almost 324 million by the year 2050. Prevalence was almost double in males (26.1%) compared to females (13.1%). Chronic obstructive pulmonary disease (COPD) was the most prevalent respiratory disease (10.6%), followed by bronchial asthma and tuberculosis. Around 12%–24% increase in geriatric emergency patient visits is estimated in both developed and developing countries. Chronic lower respiratory tract diseases are now the second- to third-leading cause of mortality in individuals aged 65 years and older. The multifactorial etiology, coupled with age-induced physiological decline, demands a comprehensive assessment with a holistic approach into not only the physical domain but also in cognitive, functional, and nutritional domains. Geriatric pulmonology demands a nuanced, patient-centric approach that incorporates advanced diagnostics, multimorbidity management, and the latest in digital health technology (DHT). Age-related structural changes include thoracic cage stiffening, reduced vertebral height due to osteoporosis, and increased alveolar duct diameter. Functionally, there is a significant decline in vital capacity, forced expiratory volume in one second, and oxygen uptake. Cellular senescence in alveolar epithelial cells, impaired endothelial responses, and altered immune cell functions compromise lung repair and immune defenses, increasing vulnerability to infections and chronic respiratory disorders. COPD affects over 55 million individuals in India alone, ranking as a top cause of death due to noncommunicable diseases. Risk factors in the elderly include cumulative smoking exposure, indoor biomass use, posttuberculosis sequelae, occupational exposure, and air pollution. Elderly patients have frequent exacerbations, often complicated by comorbidities such as cardiovascular disease, anxiety, and depression. Asthma prevalence in those aged 65+ ranges between 5.4% and 10.7%, often complicated by underreporting, diagnostic overlap with COPD, and treatment challenges due to poor inhaler technique. Community-acquired pneumonia occurs at a rate of 25–44 per 1000 older adults annually and is associated with high mortality rates up to 50%. Risk increases significantly after age 75. Pulmonary embolism accounts for 10% of hospital deaths and is often misdiagnosed due to symptom overlap with other conditions advanced imaging (CTPA) is reliable, but elderly patients have an increased risk of contrast-induced nephropathy (CIN). Interstitial lung disease (ILD) incidence in those >75 years is 200 per 100,000. Idiopathic pulmonary fibrosis is the most common subtype. Diagnosis requires high-resolution computed tomography (HRCT), and GERD and Obstructive Sleep Apnea (OSA) are common comorbidities in the elderly. Most lung cancer cases occur after age 65. Elderly patients present with comorbidities, reduced tolerance to chemotherapy, and higher prevalence of targetable mutations (e.g. KRAS, MET exon 14). Individualized treatment plans are necessary to balance survival and quality of life with advanced care directives in place. Elderly individuals are more prone to reactivation of latent TB. Comorbidities (e.g., CKD, diabetes), drug interactions, and frailty increase the complexity of management. Challenges in diagnosis and management in general among the elderly include atypical symptoms, cognitive decline, poor manual dexterity, visual/hearing impairment, comorbidity interference, and sarcopenia affecting medication adherence and mask symptom progression. Standard chest imaging is limited by difficulties in giving an appropriate position. CT imaging may be hampered by motion artifacts. Interventions like bronchoscopy require caution due to sedation sensitivity. CTPA in elderly patients increases the risk of CIN. Traditional management approaches often face limitations due to factors such as reduced mobility, comorbidities, and healthcare access barriers. The advent of DHT, including telemedicine, mobile health applications, wearable devices, artificial intelligence (AI) smart inhalers, and home-based respiratory monitoring, has the potential to transform respiratory care by enabling remote monitoring, personalized interventions, and improved patient–provider communication. DHT offers promising solutions to improve upon disease management and patient engagement. In COPD and asthma, DHTs facilitate early detection of exacerbations and support self-management. Wearable devices monitor physiological parameters, enabling timely interventions. AI algorithms assist in predicting disease progression and tailoring treatment plans. Smart inhalers equipped with sensors track medication usage and provide reminders, improving adherence. Mobile applications provide educational resources and symptom tracking, enhancing patient engagement. Mobile health applications allow patients to monitor symptoms and environmental triggers, facilitating proactive management. Telemedicine services offer remote consultations, ensuring continuity of care. In ILD home-based spirometry devices enable regular monitoring of lung function in ILD patients, aiding in the early detection of disease progression. Digital platforms provide educational content and support networks, empowering patients in self-management. AI tools assist in analyzing imaging data for accurate diagnosis and prognosis. In OSA telemedicine facilitates the diagnosis and management of OSA through remote consultations and monitoring. Wearable devices and mobile applications track sleep patterns and adherence to continuous positive airway pressure therapy, enhancing treatment outcomes. DHT has potential to enhance precision medicine and give targeted therapies. Gene therapy and mHealth (mobile support tools) further enhance patient adherence and outcomes. Despite the potential benefits, several challenges hinder the widespread adoption of DHTs among the elderly. These include digital literacy barriers, data privacy concerns, establishing stable, wide Internet coverage, addressing data accuracy, adherence to monitoring, language barriers, and the need for user-friendly interfaces tailored to older adults. Ensuring equitable access to technology and integrating DHTs into existing healthcare systems are critical for successful implementation. Research in lung ageing will give better insight into cellular senescence, aging fibroblasts, and environmental pollution effects and to develop targeted treatment for chronic respiratory diseases will improve survival outcomes in the elderly.