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Diagnosis and Treatment of Asthma in Elderly Patients

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The Official Publication of AAN - MA

Diagnosis and Treatment of Asthma in Elderly Patients

This article first appeared in the respiratory therapists' monthly magazine, AARC Times. While it contains some medical terminology, those adults who are being diagnosed with asthma later in life may find this information useful.
Editor

The diagnosis and treatment of asthma are often focused on younger patients. However, over the last several years there has been a rise in asthma diagnosis in the elderly population. More than 1 million American adults older than age 65 carry a diagnosis of asthma, affecting approximately 5–7% of adults in this age range. However, the number of seniors with this condition is no doubt much higher since asthma is one of the most under-diagnosed diseases in the United States, especially among older adults. According to the National Hospital Discharge Survey, hospitalizations for asthma are approximately 27.2 per 10,000 in the 65+ age group. This is second only to the 0–17 age group, with approximately 28.4 per 10,000.1 In addition, according to the Centers for Disease Control and Prevention (CDC), there were approximately 5.8 asthma deaths per 100,000 in the 65+ age group from the years 2001–2003. The National Health Interview Survey reports that current asthma prevalence in elderly adults is highest among Puerto Ricans.2

Asthma diagnosis difficult in the geriatric population
Chest “tightness,” shortness of breath, cough, and wheezing are nonspecific and may be manifestations of asthma or other diseases commonly seen in older adults. These diseases include congestive heart failure and COPD. Cough tends to be a prominent manifestation of asthma in this age group but may also be commonly associated with reflux and post nasal drip. Furthermore, elderly asthmatics may have a blunted acute bronchodilator response, a response that may reflect the pathophysiology of COPD rather than that of asthma. However, this may be due to a decreased number of beta-adrenergic receptors on bronchial smooth muscle in older subjects.3

A history of atopic disease in this age group is strongly suggestive of asthma. Allergic rhinitis, sinusitis, and nasal polyps may all accompany asthma. Different allergic triggers may be more common among seniors than younger adults. For example, it has been estimated that elderly asthmatic patients living in the inner city have been sensitized to cockroach antigen and that patients with cockroach sensitization may have an increased risk for asthma morbidity.4 Respiratory tract infections are a major precipitating factor of asthma in elderly patients as well. These infections can be more prolonged and resistant to treatment in older patients. The reasons are still being studied, but researchers suggest reduced immune responses and previous lung damage may play a role in these differences. Furthermore, current evidence suggests elderly patients may have reduced symptom perception and may present later in their disease course, leading to delays in treatment and more severe exacerbations.5

According to the CDC, asthma deaths in the elderly population account for more than 50% of asthma fatalities annually.6 In a study by Lee et al, elderly asthmatics had significantly more near-fatal episodes as well.7 Factors thought to contribute to such risk include:

  • Delay in diagnosis and treatment
  • Poor cardiorespiratory reserve
  • Impaired perception of increasing air-way obstruction
  • Blunted hypoxic ventilatory drive
  • Psychosocial problems
  • Cognitive problems

At diagnosis, elderly asthmatics tend to present with longstanding symptoms or they may have “late-onset” disease, typically over 65 years of age. Patients with longstanding asthma have more atopic disease and less reversible airflow obstruction consistent with “airway remodeling” (structural damage to lung tissue and airways).8 Those who present with “late-onset” asthma tend to have less allergic-mediated disease, more preserved pulmonary function, and more substantial responses to bronchodilators.

Spirometry has been used as a “gold standard” in diagnosis and monitoring treatment in asthma. However, it is estimated that less than 25% of elderly patients who present with cough and shortness of breath will be tested, often because of compromised access to care, patient underrating of symptoms, and confounding medical illnesses.9 Furthermore, in approximately 8% of elderly asthmatics, airway obstruction is absent at time of testing; and further testing, which may include methacholine challenge testing or even cardiopulmonary exercise stress testing, may be indicated to facilitate a diagnosis. In subjects thought to be at risk, spirometry should be obtained first. In those without evidence of obstruction but who remain at risk, methacholine challenge testing can be used to further refine the probability that asthma is present. However, this test is not 100% sensitive or specific for asthma; and as a measure of airway hyperresponsiveness, it may not be predictably accurate in the elderly population.10 Other features, such as measuring the carbon monoxide diffusing capacity of the lung (DLCO), may help distinguish between COPD and asthma. In the setting of airflow obstruction, a reduced DLCO value may suggest emphysema while a normal or increased value is more supportive of asthma.

Treatment options
Treatment approach to asthma in the elderly population should not differ from that in younger subjects and should include trigger control, drug optimization, and effective education.11 However, an individualized approach to care is often needed due to the many comorbid conditions this group of patients may have. For example, gastroesophageal reflux disease should be treated or ruled out, as it serves as a major precipitant and mimic of asthma in elderly subjects. Influenza and pneumococcal vaccinations should be administered to prevent or mitigate infection-related asthma exacerbations. Alterations in care plans may need to be made due to the emotional, social, and psychological changes that are associated with the aging process. Older asthmatics also may have problems with reliable transportation or prescription costs, which may interfere with disease control. In addition, many elderly patients have poor neuromuscular coordination or arthritic limitations that hinder them from using a metered-dose inhaler (MDI) or peak flow meter correctly. Use of spacers with inhalers or changing to dry-powder inhalers or nebulized medications may improve drug delivery to the lower airways in many cases.

Asthma pharmacotherapy entails additional risk for adverse drug interactions or effects in elderly patients. Several classes of medications used more frequently in older people may trigger or worsen asthma. Some of these include aspirin and other anti-inflamma tory medications used to treat arthritis and other pain syndromes. Beta-blocking agents for hypertension and glaucoma are all known to potentially cause or worsen asthma attacks. Ace inhibitors for hypertension and diabetes may worsen or mimic asthma-associated cough. Symptoms suggestive of these adverse drug effects may be as subtle as new cough, decreased exercise tolerance, wheezing, or shortness of breath. Beta-2 agonists may aggravate ischemic heart disease and can also cause tachyarrhythmias. Steroids may accelerate osteoporosis, decrease serum potassium levels, and worsen congestive heart failure. Methylxanthines, such as aminophylline and theophylline, if used, can cause rapid heart rates, headache, nausea, and seizures. Close monitoring of blood levels is warranted if prescribing these medications.

Invite patients to participate in their own care
Optimal treatment of asthma in elderly patients may result in reduced emergency room visits and hospitalizations, improved quality of life, preserved activity levels, and more stable pulmonary function over time. Timely diagnosis and treatment will best ensure these treatment goals are achieved. Physicians must establish simple, effective treatment plans and encourage open communication with their patients to minimize noncompliance or treatment failures in this age group. Patients must also be invited to participate in their care, which may help them gain improved control over symptoms long term. Patients can be taught to avoid asthma triggers, monitor peak flow rates, and seek medical attention when needed. This shared-care approach, when possible, should improve patient outcomes and give older asthmatics more room to “breathe freely.” •

References

  1. 1. Centers for Disease Control and Prevention web site. Advance data from vital and health statistics, No. 317. Available at http://www.cdc.gov/nchs/data/ad/ad317.pdf Accessed May 4, 2006
  2. 2. Centers for Disease Control and Prevention web site. National Center for Health Statistics. Available at www.cdc.gov/nchs/products/pubs/pubd/hestats/ashtma03-05/asthma03-05.htm Accessed Jan. 10, 2007
  3. 3. de Bisschop C, Marty ML, Tessier JF, et al. Expiratory flow limitation and obstruction in the elderly. Eur Respir J 2005; 26(4):594-601.
  4. 4. Rogers L, Cassino C, Berger KI, et al. Asthma in the elderly: cockroach sensitization and severity of airway obstruction in elderly nonsmokers. Chest 2002; 122(5):1580-1586.
  5. 5. Bellia V, Battaglia S, Catalano F, et al. Aging and disability affect misdiagnosis of COPD in elderly asthmatics. Chest 2003; 123(4):1066-1072.
  6. 6. Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthama — United States, 1980–1999. MMWR Surveill Summ 2002; 51(1):1-13.
  7. 7. Lee KH, Chin NK, Lim TK. Asthma in the elderly — a more severe disease. Singapore Med J 2000; 41(2):579-581.
  8. 8. Braman SS, Kaemmerlen JT, Davis SM. Asthma in the elderly. A comparison between patients with recently acquired and long-standing disease. Am Rev Respir Dis 1991; 143(2):336-340.
  9. 9. Parameswaran K, Hildreth AJ, Chadha D, et al. Asthma in the elderly: underperceived, underdiagnosed and undertreated; a community survey. Respir Med 1998; 92(3):573-577.
  10. 10. Cuttitta G, Cibella F, Bellia V, et al. Changes in FVC during methacholine-induced bronchoconstriction in elderly patients with asthma: bronchial hyperresponsiveness and aging. Chest 2001; 119(6): 1685-1690.
  11. 11. National Institutes of Health; National Heart, Lung, and Blood Institute. NAEPP working group report: considerations for diagnosing and managing asthma in the elderly. NIH Publication No. 96-3662, 1996.

Additional Reading
American Academy of Allergy Asthma & Immunology web site. Seniors and asthma — distinguishing asthma from a heart condition. Available at: www.aaaai.org/patients/seniorsandasthma/distinguishing_asthma_heartattack.stm Accessed Nov. 25, 2006

Enright P. The diagnosis of asthma in older patients. Exp Lung Res 2005; 1 Suppl:15-21.

Health-Cares.net web site. What’s the treatment for asthma in the elderly? Available at http://respiratory-lung.health-cares.net/elderly-asthma-treatment.php Accessed Dec. 28, 2006

Morris MJ. Difficulties with diagnosing asthma in the elderly. Chest 1999; 116(3):591-593.

 

About the Authors
John P. Krcmarik, MD, FCCP, is board certified in pulmonary critical care and sleep medicine. He is the medical director of respiratory care and pulmonary rehab at Munson Medical Center in Traverse City, MI.

About the Authors
Karen P. Kain, MS, RRT-NPS, AE-C, is the pulmonary education/rehab coordinator in the respiratory care department at Munson Medical Center.

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