Pharmacological Challenges In The Treatment Of Geriatric Asthma
Asthma in the geriatric population appears to be widely undertreated . The treatment of asthma in geriatric age follows international guidelines , although most recommendations are extrapolated from findings in younger subjects. As already discussed, older age has always represented an exclusion criterion for eligibility in clinical trials and current asthma medications have never been tested in elderly asthmatics. The care of older asthmatics should address different domains such as comorbidities and polypharmacotherapy. The latter has been demonstrated to be one of the strongest predictors and the most important risk factor for adverse drug reactions in the elderly . Therefore, particular attention should be given to concomitant nonrespiratory medications, since they can interfere with respiratory drugs or with the disease . For instance, -blockers, frequently prescribed in elderly subjects who suffer from cardiovascular diseases or administered as eye drops for glaucoma, can facilitate bronchoconstriction.
Managing Your Asthma Well In Later Life
Continue to have regular asthma reviews
Whether youve had asthma all your life or youve been diagnosed with it as an older adult, an asthma review helps you stay on top of any changes in your symptoms.
You can make sure your asthma action plan is up to date, review your asthma medicines, and check youre taking the lowest dose possible to stay well and avoid side effects.
Track your symptoms
Keeping track of your symptoms makes it easier to spot any changes. Write down your symptoms in a diary, notebook, or on your phone and take it along to your next appointment.
Remember to make a note of anything you were doing that day or any triggers you came across – you may notice youre sensitive to new things that were not a problem before.
Dont ignore symptoms like breathlessness, says Dr Andy. Its easy to think that feeling a bit more breathless is just another sign that youre not as fit as you used to be.
But if youre feeling out of breath climbing stairs or walking uphill, see your GP to get it checked out. Breathlessness can be a sign that your asthma is not well controlled. It could also be a sign of another health condition.
Act quickly if symptoms get worse
To cut your risk of an asthma attack, take action as soon as you notice symptoms getting worse. As we get older, asthma attacks can be more severe and take longer to recover from.
Check your inhaler technique
Ask about side effects
Get help for other conditions too
Find out more about other conditions.
Future Directions For Research
Given the recent recognition of the heterogeneity of asthma and the growing appreciation of the morbidity and mortality among elderly asthmatics, there is a great need for further basic, translation, and clinical research targeting older patients. The recognition of the multiple mechanisms of biologic aging relevant to the asthmatic lung, including, but not limited to, telomere length, mitochondrial dysfunction, autophagy, DNA methylation, immunosenescence, and airway remodeling, is an area for research into mechanisms and potential new therapeutics in asthma. Given the newer targeted therapies on the horizon, it will also be important to determine their role in the management of elderly patients with long-standing asthma and those with late-onset asthma.
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Trigger Avoidance And The Role Of Comorbidities
Allergy has a well-known role in asthma, even if, overall, it seems to wane with age.69,70 However, asthma in the elderly may be associated with allergic triggers.70 There is scarce evidence about whether measures to create a low-allergen environment are effective for improving asthma control in the elderly. The role of specific immunotherapy in elderly asthmatics is limited, but specific allergen immunotherapy may be an appropriate adjunctive therapy when a clear relationship exists between symptoms, allergen exposure, and positivity to a skin test.71
Asthma exacerbations are often sustained in the elderly by a variety of nonallergenic triggers, such as viral infections, pollutants, and drugs. Elderly asthmatics often perceive viral infections as common triggers and two thirds reported seasonal worsening in winter.72 Patients with moderate to severe asthma should be advised to receive an influenza vaccination every year they are safe and have a small risk of pulmonary complications.73 From the 19912002 Medicare Survey, 72% of older subjects received influenza vaccinations.74
Physical activity is important for patients with chronic respiratory diseases. It has been found that exercise training improves quality of life in older asthmatics.81
Why Is Asthma Difficult To Diagnose In Older Adults
A diagnosis of asthma may be missed in an older person because symptoms of other health conditions are similar to asthma symptoms and may mask the specific symptoms. Asthma symptoms among older adults are more likely to take the form of coughing with the production of sputum from the lungs. Your physician might interpret those symptoms as being due to other illnesses, such as chronic bronchitis or congestive heart failure. In particular, heart disease and emphysema, much more common in older adults, especially smokers, can mimic asthma symptoms.
Good to know . . . One of the ways in which asthma is recognized among younger people is by the symptoms of wheezing and difficulty breathing following exercise. When older adults become inactive, the opportunity for asthma to present itself lessens. If you experience asthma symptoms wheezing, shortness of breath, tightness in the chest, chronic cough with your regular activities such as housework, shopping, gardening, or walking, be sure to talk with your physician as soon as possible.
When the asthma symptoms are not recognized correctly, they may remain untreated, likely worsening and creating very serious health risks.
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Airway Remodeling And Aging
Airway remodeling, structural changes in the airways and lung parenchyma, can occur in asthma and is felt in part to be secondary to persistent inflammation. The features of airway remodeling include subepithelial fibrosis, goblet, and submucosal gland hyperplasia, increased airway smooth muscle mass, and increased airway vascularity and occur in both the large and small airways and in patients with all disease severities. The duration of asthma likely impacts airway remodeling therefore, it is hypothesized that older patients with LSA have increased features of airway remodeling however, this has not been definitively established.
Are There Special Considerations In Treating Asthma In Older Adults
Yes. First of all, treatment of asthma for older adults can be complicated by the fact that so many older people take multiple medications for various health conditions. Some asthma medications can react with those other treatments, causing unpleasant side effects. In addition, other medications may actually worsen asthma symptoms.
Secondly, older patients are more likely than younger patients to have mental confusion or memory problems. This may be the result of normal aging or of an illness, such as Alzheimers disease. Whatever the cause, these problems can make it difficult for certain older patients to follow treatment instructions especially if that person takes medications for a variety of health conditions.
Additionally, many asthma medications come in the form of an L-shaped metered dose inhaler which requires a certain degree of manual coordination and dexterity. Older people are more likely to have difficulty with this type of medication device, and in using it, may not receive the correct dose. Treatment with a dry powder inhaler or oral medications can help older asthma patients avoid problems with use of L-shaped inhalers.
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Managing Asthma In Older Adults
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- Seminars in respiratory and critical care medicine
Asthma In The Elderly: Important Considerations For Diagnosis And Treatment
Asthma affects between 4% and 13% of adults in the United States aged 65 years and older.1 People in this older population are > 5 times more likely to die from asthma than their younger counterparts.1 Furthermore, by 2050, the number of people in the world aged 65 and older is expected to almost triple.1 Yet, Asthma in the elderly remains under-recognized, undertreated, and a challenge to properly diagnose and treat.
Asthma in older adults is shown to have a significant impact on quality of life. Many times, asthma in the elderly coexists with conditions such as obesity, decreased immunity, and chronic obstructive pulmonary disease all of which are common among this population. As a result, asthma can often be complex and difficult to spot in the elderly.
Pathogenesis of Asthma in Older Adults
Poor respiratory muscle strength, decrease in elastic recoil, and greater rigidity of the chest wall are often all part of the natural aging process that may contribute to the onset of asthma.1 Forced expiratory volume in one second and forced vital capacity each decrease by between 25 and 30 mL every year after around the age of 20.2 This is usually what contributes to reduced respiratory muscle strength and decrease in elastic recoil in older adults.
Challenges of Diagnosing Asthma in the Elderly
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Symptoms Like Coughing Wheezing And Feeling Breathless Could Mean You Have Asthma See Your Gp To Confirm A Diagnosis Of Asthma And Start Treatment
Find out why its important to get a diagnosis so you can start treatment for asthma, how asthma is diagnosed, and how you can take positive steps to stay symptom free after a diagnosis.
- tightness in the chest
- feeling short of breath.
Not everyone with asthma will get all of these. For example, not everyone wheezes. But if youre experiencing one or more of these symptoms, make an appointment with your GP.
Most people with well-managed asthma only have symptoms now and then. But some people have symptoms a lot of the time, particularly the small percentage of people with severe asthma.
A key thing with asthma is that symptoms come and go you may not have them all the time.
Why its important to see your GP to confirm a diagnosis
If youve noticed asthma-like symptoms, dont ignore them. Make an appointment with your GP or an asthma nurse as soon as you can.
The quicker you get diagnosed, the quicker you can get the right medicines to help you deal with your symptoms.
Asthma is a long-term condition that needs regular preventer treatment. If its not treated, it could lead to an asthma attack which can be life-threatening.
Why Is Adult Onset
Adult onset-asthma symptoms are often blamed on other chronic health issues more common in adults, such as:
- Stomach problems and conditions such as gastroesophageal reflux disease
- Physical deconditioning caused by inactivity, excess weight, or the effects of aging
The delay in an accurate diagnosis and appropriate treatment often leads to worsening lung function that makes adult-onset asthma more difficult to treat from the start.
Unfortunately, many of the medications used to treat asthma can interfere with the drugs used for coexisting, adult-type conditions such as heart failure, hypertension, and many others. This makes it more difficult to design an effective treatment strategy for adults with asthma.
Also, the muscles in your chest wall become weaker and lungs lose elasticity as you age, which can increase the problems associated with asthma and decrease the effectiveness of treatment in adults. This makes it doubly important that your asthma treatment plan is tailored to fit your circumstance.
For an effective, customized treatment plan thats designed to address the effects of adult-onset asthma, schedule an evaluation at Tristate Pulmonary Medical Practice today. Call our office or book your visit online.
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How Is Asthma Different In Older Adults
Most people with asthma experience their first symptoms at a young age. But asthma can develop for anyone at any age. It is not uncommon for adults in their 70s or 80s to develop asthma symptoms for the first time. When asthma does occur at a later age, the symptoms are much like those experienced by anyone else. The most common causes of an asthma flare up are a respiratory infection or virus, exercise, allergens, and air pollution . Allergens and irritants are substances found in our everyday environment. People who have asthma may experience wheezing, cough, shortness of breath, and chest tightness.
Asthma creates a much greater risk for older adults because they are more likely to develop respiratory failure as a result of the asthma, even during mild episodes of symptoms.
Did you know . . . Older patients with mild asthma symptoms can have the same level of breathing difficulty as younger asthma patients experiencing a severe asthma episode?
Unlike asthma in younger persons, asthma in older adults rarely goes into remission. Instead, asthma is more likely to remain a potentially serious, and many times, a disabling disease.
When Asthma Appears Later In Life You Can Breathe Easier When It Is Managed Well
Chris Haromy has lived with asthma since childhood. He is also a registered respiratory therapist and certified respiratory educator with The Lung Association Ontario. Ive learned to stay on top of my asthma, constantly monitoring my health, taking all of my medication as prescribed, and living a healthy lifestyle. When hes not in the office, he is often out jogging or playing soccer.
Haromy has spent the last 21 years or more developing and providing patient education programs for children and adults to help them manage the vagaries of life with asthma, including the swelling and inflammation in the lining of airways , the coughing attacks, and the muscle contractions that narrow the airways all of which make breathing difficult.
In this country, 12.2 percent of children have the chronic disease, but its not limited to young people. About 6.3 percent of adults live with it, too many of whom were diagnosed after age 50, according to data from the Ontario Ministry of Health and Long-Term Care.
its a big adjustment for someone to be diagnosed with asthma as an adult.
Of course, its a big adjustment for someone to be diagnosed with asthma as an adult, says Haromy. But theres a lot they can do to ensure they continue living a full, active life. But the reality is, half of the people who have asthma dont manage it well. So many people with asthma seem resigned to just putting up with it.
- occupational exposures
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Asthma Is Common And Troublesome In The Elderly
Asthma is a respiratory disease characterized by variable respiratory symptoms and airway obstruction associated with airway hyperresponsiveness . These features are generally attributed to an airway inflammatory process with progressive bronchial remodelling .
The prevalence of asthma in the elderly has been reported to be equal or even higher than in the general asthmatic population . As an example, the lifetime and current prevalence of asthma in patients over 65 years old was 10.6 and 7.0 % according to a study performed in the United States . However, elderly patients have the highest asthma-related mortality, estimated at 51.3 million persons in USA in 2001 . Furthermore, they have a higher morbidity and rate of hospital admission for asthma than younger patients . This has been attributed to a frequent under- or mis-diagnosis, poor assessment and under-treatment of asthma in this group, but also related to many patients-related care gaps in the management of asthma in this population . Mortality rate from asthma is higher in the elderly than in younger patients of any other age group. Furthermore, many elderly asthmatic patients consider that their respiratory symptoms are normal, associated with aging and they often delay their consultation to a physician or to the ED, in addition to have many fears and misconceptions about their treatment .
Table 1 Some characteristics of asthma in the elderly
Asthma In Older Adults
The Centers for Disease Control and Prevention reports that nearly 7 percent of people age 65 and older have asthma.
To treat their asthma, people use an inhaled corticosteroid that inhibits the inflammation that causes asthma. It also helps to prevent asthma and improve lung function.
People with asthma also use a bronchodilator to expand bronchial air passages and to ease breathing.
Asthma is intermittent or persistent, Wechsler said. If its persistent, its either moderate or severe, and the frequency interferes with daily life. If symptoms occur two times a week, the asthma is persistent. If four to five days a week, its moderate. If daily, its severe.
Wechsler said physicians gauge the severity of a persons asthma and treat it accordingly.
We ask, is a persons asthma well-controlled based on what I do? he said. What is the frequency of exacerbation, or flares of the disease? What is the level of lung function, based on age, sex, gender, race, and height?
Older people have lungs that are aging and have lower lung function, Wechsler said.
Their respiratory muscles are weaker from poor nutrition and from comorbidities such as cardiac and kidney disease, which are associated with muscle weakness, and they have less elastic recoil in the chest wall and lungs, he explained.
Aging also dulls the immune systems response to inflammation, Wechsler noted. That is a key contributor to asthma.
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Other Ways To Stay Well In Later Life
Stay active
Studies have shown that people who keep exercising have more chance of staying healthy as they get older.
Even if your mobility isnt as good as it was or you find you get tired easily, there will be an activity you can do.
Keep to a healthy weight
Keeping to a healthy weight can lower your risk of asthma symptoms. Studies show that if youre very overweight, even losing a bit of weight, can make a difference to your asthma.
It can feel harder to shift the weight as you get older, particularly if youre less active than you were. Find out what support you can get.
Stop smoking
If you smoke, youre more at risk from asthma symptoms and attacks, as well as COPD.
Giving up smoking not only lowers your risk, but it also means your medicines will be more effective.
Look after your mental health
If youre worried, down, or lonely, talk to someone about how you feel. Age UK has an Advice Line: 0800 169 2081.
Stress, anxiety and depression can all trigger asthma symptoms.
We all need a support network of friends, family and neighbours, says Dr Andy. Share your asthma action plan, so that anyone caring for you knows what to do if symptoms get worse and who to call for help. And tell your GP or asthma nurse how youre feeling too.
You can talk to a respiratory nurse specialist on our Helpline: 0300 222 5800 . Or you can WhatsApp them on 07378 606 728
Next review due December 2023