Asthma in Seniors

Asthma is sometimes thought of as a "childhood disease," but it is often diagnosed as a new condition in older people. For other people, it may be a continuing problem from younger years. In Michigan, asthma affects nearly 11% of adults and an estimated 7% of residents aged 75 and older (MI BRFS, 2016).

Diagnosing Asthma in Older People

The differential diagnosis of episodic chest symptoms in the elderly expands as cardiovascular disease and other forms of chronic lung disease become more prevalent. It is important not to misdiagnose asthma as chronic obstructive pulmonary disease (COPD) because asthma has a different natural history and a better prognosis with treatment.

A person may have asthma if they:

• Present with episodic wheeze, chest tightness, shortness of breath, or cough.
• Have recurrent coughing or wheezing episodes as the only symptom.
• Have asthma symptoms that vary throughout the day.
• Have symptoms that worsen at night, while exercising, or in the presence of airborne allergens or irritants.
• Present with allergic rhinitis or atopic dermatitis.
• Have relatives with asthma, allergy, sinusitis, or rhinitis.
• Have a physical exam which reveals:
• Hyperextension of the thorax.
• Wheezing, or prolonged or forced exhalation.
• Nasal secretions, sinusitis, rhinitis, or nasal polyps.
• Atopic dermatitis/eczema, or allergic skin problems

Remember, the absence of symptoms at the time of a physical exam does not exclude an asthma diagnosis.

To establish an asthma diagnosis:

• Perform an asthma-specific medical history and physical exam. Be sure to review all medications the patient is taking. Beta blockers are known to induce bronchospasm as a side effect.
• Document by spirometry that airflow obstruction exists and is partially reversible, i.e.:
• FEV1 is < 80% of the predicted limit
• FEV1/FVC is ≤ 75% the lower limit of normal (this ratio decreases as people age – see below values)
• Age-Adjusted Normal FEV1/FVC:
• 8 – 19 years 85%
• 20 – 39 years 80%
• 40 – 59 years 75%
• 60 – 80 years 70%
• FEV1 increases > 12% and at least 200mL after use of a short-acting inhaled beta2- agonist (i.e., albuterol)
• Older adults may need to use oral steroids for 2–3 weeks before taking the spirometry test to measure the degree of reversibility achieved. Chronic bronchitis and emphysema may coexist with asthma in adults.
• Exclude alternative diagnoses (e.g., vocal cord dysfunction, vascular rings, foreign bodies, other pulmonary diseases), using additional tests if necessary.
• Normal spirometry does not exclude the diagnosis of asthma.

Additional tests may be required when the patient presents with:	Appropriate tests may be:
Asthma symptoms but spirometry is normal	Airway resistance Methacholine challenge Exercise challenge Cold air challenge
Other factors contributing to asthma	Nasal exam GE reflux testing Allergy testing
Infection (i.e., sinusitis), large airway lesion, heart disease or foreign body	Chest x-ray Sinus studies
COPD, restrictive defect, or central airway obstruction	Additional PFT's, such as static lung volumes, exercise testing diffusing capacity test

Distinguishing Asthma from Chronic Obstructive Pulmonary Disease

Characteristic	For Asthma	For COPD
History
Episodic wheeze	Common	Less common; may occur with exacerbations
Nocturnal dyspnea or Cough	Common	Not common
Cough with phlegm	Present more than 40 percent of cases; common in those who smoke	Characteristic of chronic bronchitis
Other allergic symptoms (rhinitis, conjunctivitis)	Frequent	Infrequent
Smoking history	Less common	Almost always associated
Past history of asthma	Common	Uncommon
Family history of allergy	Frequent	Less frequent
Physical Examination
Wheeze	Common	Common after forced expiration or cough
Laboratory Findings
Pulmonary function	Similar to COPD	Similar to asthma
Chest x-ray	Often normal; may show hyperinflation	↓ vessels, focal hyperaeration (emphysema) ↑ markings (chronic bronchitis)
Eosinophilia	More common	Less common
Positive skin tests	More common	Less common
Total serum IgE	Usually elevated	Elevation less common
Response to Therapy
FEV 1 response to beta 2-agonist	FEV 1 with symptom relief	Little/no change in FEV 1 with poor symptom relief

Treating Asthma in Seniors

The goals of asthma treatment are to:

• Prevent chronic asthma symptoms and asthma attacks during the day and night
• Maintain normal activity levels, including exercise and other physical activities.
• Have normal or near-normal lung function.
• Be satisfied with the asthma care received.
• Have no or the least side effects while getting the best medications.

Treating asthma in the elderly is complicated due to interactions among effects of aging, asthma and coexisting conditions.

• Normal aging-associated changes in lung structure are likely to exaggerate asthma symptoms. These changes sometimes make it difficult to distinguish clearly between asthma and COPD, especially in patients who have smoked.
• Patients with COPD often have a reversible component to their condition, and asthma medications may relieve some symptoms and improve the patient's quality of life.
• Elderly patients may have a decreased response to influenza immunization as well as to pneumococcal vaccine and tetanus toxoid.
• Patient education and asthma management plans for elderly patients should take into consideration possible decreased ability to handle multiple complex stimuli, memory problems, loss of coordination and muscle strength that make it difficult to use metered-dose inhalers, hearing and visual difficulties, sleep disturbances that may impair cognitive function, and depression.
• Adverse asthma reactions from medications related to polypharmacy are greater in the elderly. It is important to ask what other medications the elderly patient with asthma is taking. Particularly hazardous are beta-adrenergic blocking agents (even ophthalmic preparations) and, in some patients, non-steroidal anti-inflammatory drugs and antidepressants.

Non-asthma Medications with Increased Potential for Adverse Effects in the Elderly Patient with Asthma

Medication	Comorbid Conditions For Which Drug is Prescribed	Adverse Effect	Comment
Beta-adrenergic blocking agent	Hypertension Heart Disease Tremor Glaucoma	Worsening Asthma bronchospasm Decreased response to bronchodilator	Avoid where possible; when must be used, use a highly beta-selective drug
Nonsteroidal anti- inflammatory drugs	Arthritis Musculoskeletal diseases	Worsening asthma bronchospasm	Not all elderly with asthma have nontolerance of NSAIDs, but are best avoided if possible
Non-potassium- sparing diuretics	Hypertension Congestive heart failure	Worsening cardiac function/ dysrhythmias due to hypokalemia	Additive effect with antiasthma medications that also produce potassium loss (steroids, beta-agonist); elderly also more likely to be receiving drugs (e.g., digitalis) where hypokalemia is of increased concern
Cholinergic agents	Urinary retention Glaucoma	Bronchospasm Bronchorrhea	Also note that some over- the-counter asthma medications contain ephedrine, which could aggravate urinary retention, glaucoma
ACE inhibitors	Heart failure Hypertension	Increased incidence of cough

Management of Asthma in Older People

• All patients need to have regular visits scheduled for their asthma. Older people need to have a written Asthma Action Plan that tells them exactly what to do to prevent and treat asthma symptoms. The plan should be in large print, if necessary, and reviewed at each office visit.
• Elderly patients may need assistance in order to keep their asthma under control. They may have difficulty with transportation, prescription costs or emotional stress.
• Desired therapeutic and clinical outcomes may be more difficult to achieve in elderly patients with asthma. Normal lung function may either be unattainable or be attainable only with potentially dangerous, high pharmacologic doses. It is important, therefore, to set realistic goals for therapy. Treatment goals may need to be modified to maintain a desirable quality of life.
• Because compliance with multiple therapies – for both asthma and coexisting diseases and conditions – may be difficult, elderly patients often need special education and training in using asthma medications and devices.
• The potential for drug interactions is greater in elderly patients with asthma because these patients are likely to be on multiple medications for other conditions, particularly heart disease.
• Beta2-agonists and theophylline use should be monitored carefully because they can cause tachyarrhythmias and aggravate ischemic heart disease.
• If theophylline is used, it should be used with caution, especially in patients with congestive heart failure.
• o Systemic corticosteriods may aggravate congestive heart failure, lower serum potassium with potentially adverse cardiac effects or, in diabetics, increase blood sugar levels.
• Corticosteroids in high doses may reduce bone mineral content and may accelerate development of osteoporosis.
• The usefulness of PEF monitoring may be limited by age-related factors that compromise the effort and perceptual and motor skills required for accurate measurements.
• Avoidance of environmental triggers, including tobacco smoke and other airborne irritants to which the patient is sensitive, is useful for many elderly patients with asthma.
• It is important that physicians have a regular follow-up visit with their patients with asthma. This should be done at least yearly. The following chart provides the basic elements of a follow-up visit for asthma with a doctor or asthma educator.
• A critical element to managing asthma is education:
1. Assess the needs of your patient
2. Set mutually-developed objectives
3. Try to work out any barriers that stand in the patient's way
4. Create a relaxed, learner-friendly environment
5. Try different styles of delivery of the educational material
6. Assess how well the patient is learning/understanding the material
7. Refer to formal asthma education programs in the community

Learn when to refer patients to an asthma specialist.

Basic Elements of a Follow-up Office Visit for Asthma with a Doctor or Asthma Educator

1. The clinician should ask the patient if he or she has experienced a change in symptoms:
• Nocturnal or early morning awakening with wheezing and cough
• Shortness of breath
• Cough or phlegm
• Acute episodes of shortness of breath or wheezing
2. The clinician should ask the patient if he or she has experienced a change in exercise tolerance or inability to perform at the usual level of exertion.
3. The clinician should ask the patient about medications taken, including:
• All prescribed and over-the-counter medications and "health food" preparations
• Asthma medications and those for other problems
• Dosage and frequency
• Any increase or change in drug use, especially beta2-agonists.
4. The clinician should note physical findings, especially:
• Change in ventilatory pattern at rest (accessory muscle use, forced expiration)
• Change in ventilatory pattern with activity
• Ability to speak in full sentences
• Signs of airflow obstruction (expiratory slowing, wheeze, poor aeration)
• Signs and symptoms of poor oxygenation (tachycardia, cyanosis)
• Signs of heart failure (edema, gallop rhythm, neck vein distension).
5. Perform spirometry. The clinician should review PEF home monitoring records, if the patient uses PEF at home, and provide feedback about the observations. PEF should only be used with patients with moderate to severe asthma.
6. The clinician should observe the patient's metered-dose inhaler and other delivery device techniques (discus, flexhaler, etc.) and provide appropriate feedback.
7. The clinician should review the patient's Asthma Management Plan.

SPECIAL ISSUES FOR OLDER ADULTS

Assessment Issues

The Expert Panel recommends that the extent of reversible airflow obstruction be determined because of the high prevalence of other obstructive lung disease (e.g., chronic bronchitis, emphysema) among the elderly. Careful evaluation is required, because the precise cause of severe airflow obstruction can be difficult to identify in older patients who have asthma. A 2- to 3-week trial of therapy with systemic corticosteroids can help detect the presence of significant reversibility of the airway disease. Long-term control asthma medication can then be offered.

Treatment Issues

The Expert Panel recommends that adjustments in therapy may be necessary because asthma medications may have increased adverse effects in the elderly patient.

• Airway response to bronchodilators may change with age, although this is not clearly established. Older patients, especially those with preexisting ischemic heart disease, may also be more sensitive to beta2-agonist side effects, including tremor and tachycardia. Concomitant use of an anticholinergic and a short-acting beta-agonist (SABA) may be beneficial to the older patient.
• Theophylline clearance is reduced in elderly patients causing increased blood levels of theophylline. In addition, age is an independent risk factor for developing life-threatening events from iatrogenic chronic theophylline overdose (patients 75 years of age or older have a 16-fold greater risk of death from theophylline overdose than do 25-year-old patients). The potential for drug interaction—especially with antibiotics and H2-histamine antagonists such as cimetidine—is greater because of the increased use of medications in this age group. Theophylline and epinephrine may exacerbate underlying heart conditions.
• Systemic corticosteroids can provoke confusion, agitation, and changes in glucose metabolism.
• Inhaled corticosteroids.
• Consider concurrent treatments with calcium supplements and vitamin D, and bone-sparing medications (e.g., bisphosphonates) in patients who have risk factors for osteoporosis or low bone mineral density.
• ICS use may be associated with a dose-dependent reduction in bone mineral content, although low or medium doses appear to have no major adverse effect. Elderly patients may be more at risk due to preexisting osteoporosis, changes in estrogen levels that affect calcium utilization, and a sedentary lifestyle.
• The risk of not adequately controlling asthma may limit unnecessarily the patient's mobility and activities approach for identifying patients at risk for accelerated bone loss from high-dose ICS therapy is to conduct bone densitometry when treatment begins and again 6 months later, although the benefits of this approach have not yet been evaluated in clinical trials.
• The Expert Panel recommends that medications taken for other diseases and conditions be adjusted as necessary, because some medications may exacerbate asthma. Non-steroidal anti-inflammatory agents for treating arthritis, beta-blockers for treating hypertension (particularly nonselective beta-blockers), or beta-blockers found in some eye drops used to treat glaucoma may exacerbate asthma.
• The Expert Panel recommends that review of the patient’s technique in using medications and devices is essential. Observation of technique for use of inhaler devices, peak flow meters, and spirometry is especially important in the elderly because physical (e.g., arthritis, visual) and cognitive impairments (recognized or unrecognized) can make acquisition and retention of proper technique difficult.