Asthma in Older Adults

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Asthma is a chronic inflammatory disease characterized by hyper-responsiveness of airways to various stimuli. This complex disease affects patients of all ages. Although asthma has an equal incidence across all age groups, asthma in the elderly is often underdiagnosed and undertreated. A case-control cohort study showed that older adults with asthma have a higher rate of allergic sensitization, decreased lung function, and significantly worse quality of life when compared with controls. ^[1]

Some of the stimuli or triggers may generally be subdivided into allergic (allergens such as pollen, molds and fungi, dust mites, pet dander, and insects) or nonallergic (eg, cold air, infections, diesel exhaust, indoor/outdoor air pollution, perfume, tobacco smoke, and other irritants). See the image below.

Medical conditions such as rhinosinusitis, gastroesophageal reflux, and aspirin or nonsteroidal anti-inflammatory agent (NSAID) sensitivity may also trigger or exacerbate asthma.

Elderly patients with asthma face disproportionate morbidity, mortality and cost when compared with younger patient groups. They represent a higher number of unscheduled outpatient visits, emergency room visits, and asthma-related hospitalizations; once hospitalized, the death rate attributable to asthma for patients older than 65 years is 14 times higher than patients aged 18-35 years. ^{[2, 3, 4, 5]}

Some of the independent risk factors for asthma in older adults include house dust mite sensitization and maternal smoking. ^[1]

Normal lung tissue and constricted lung tissue are demonstrated in the image below.

Airway inflammation, smooth muscle contraction, epithelial sloughing, mucous hypersecretion, bronchial hyperresponsiveness, and mucosal edema are some of the common pathophysiological mechanisms seen in asthma. The chronic persistent inflammation may result in airway remodeling and structural changes of the airway wall. These changes include an epithelial thickening and subepithelial fibrosis; changes of extracellular matrix are linked to deposition of collagen and fibronectin in the subepithelial basement membrane.

Various stimuli and factors may trigger asthma; this is evident by the recruitment and infiltration of proinflammatory cells within the airways. Cells such as eosinophils, neutrophils, lymphocytes, and degranulated mast cells, lead to occlusion of the bronchial lumen by mucus. See the image below.

Etiology

Allergic triggers include the following:

Pollen – Trees, grasses, weeds

Mold – Fungi

Dust mites

Animal proteins

Allergic triggers usually cause asthma symptoms by dimerizing or bridging the high affinity immunoglobulin E (IgE) receptors located on the mast cells in the lungs. See the image below.

Non-allergic triggers include the following:

Cold air

Infections – Influenza, Mycoplasma pneumonia, viruses/upper respiratory infections

Tobacco smoke

NSAIDS or aspirin

Exercise

Irritants – Perfumes, paint

Pollutants – Diesel exhaust, industrial chemicals

Occupational exposures

Over the past 40 years, the incidence rate of asthma has increased across all age groups. The incidence rate of asthma in adults older than 65 years is similar to that found in other age groups (approximately 100 cases per 100,000 population annually). ^[2]

Adult patients with asthma often stop their medications when they feel well. These patients must be monitored on a regular basis to assess symptoms and to intervene for appropriate asthma control. Adults generally expect to be treated as adults, with a respect and an appreciation for the skills they bring to the table as they have different educational levels, backgrounds, life experiences, and expectations. Adults have established values, beliefs and opinions that must be identified and respected in order to set goals for management. ^[6]

Smith A. M., Villareal M., Bernstein DI, Swikert D. J. Asthma in the elderly: risk factors and impact on physical function, Ann Allergy Asthma Immunol 108 (2012) 305-310.

Bauer BA , Reed CE , Yunginger JW , et al. Incidence and outcomes of asthma in the elderly: a population-based study in Rochester, Minnesota. Chest . 1997;111:303–310.

Enright PL , McClelland RL , Newman AB , et al. Underdiagnosis and undertreatment of asthma in the elderly (Cardiovascular Health Study Research Group). Chest . 1999;116:603–613.

Huss K.,Naumann PL, Mason PJ. Et al , Asthma severity , atopic status, allergen exposure and quality of life in the elderly persons. Ann Allergy Asthma Immunol 2001; 86: 524-530.

Asthma mortality and hospitalization among children and young adults- United States, 1980-1993. MMWR 1996;45: 350-353.

Ortiz Gabriel, Sanders DH: Adult Asthma , J. Asthma & Allergy Educators Vol 3 No. 3 June 2012.

ATS . Standardization of Spirometry, 1994 Update (American Thoracic Society). Am J Respir Crit Care Med . 1995;152:1107–113.

Tepper et al , Asthma Outcomes: Pulmonary Physiology, J. Allergy Clin Immunol 129,No. 3 , March 2012 S65.

Carr TF, Peters AT- Asthma : Principles of treatment , Allergy and Asthma Proceedings, Volume 33, No. 3, May-June 2012 Supplement 1.

Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: A practice parameter third update. J Allergy Clin Immunol 127 (suppl):S1-S55, 2011.

Delea TE, Hagiwara M, Stempel DA, and Stanford RH. Adding salmeterol to fluticasone propionate or increasing the dose of fluticasone propionate in patients with asthma. Allergy Asthma Proc 31:211—218, 2010.

Fanta CH., Asthma, N Engl J Med 2009;360:1002-1014.

Fuhlbrigge A, Jr RL, Rasouliyan L. et al. Practice patterns for oral corticosteroid burst therapy in the outpatient management of acute asthma exacerbations. Allergy Asthma Proc 33:82-89,2012.

Georgy MS, and Saltoun CA. Allergen immunotherapy: Definition, indication, and reactions. Allergy Asthma Proc 33:S9-S11, 2012.

Greenberger PA. Asthma. In Patterson’s Allergic Diseases, 7th ed. Grammer LC, and Greenberger PA (Eds). Philadelphia, PA: Lippincott, Williams & Wilkins, 333-338,2009.

Humbert M, Beasley R, Ayers J, et al. Benefits of omalizumab as add-on therapy in patient with severe persistent asthma who are inadequately controlled despite best available therapy (GINA 2002 step 4 treatment): INNOVATE. Allergy 60:309-316,2005.

Milgrom H., Berger W., Nayak A. et al, Treatment of childhood asthma with Anti- Immunoglobulin E Antibody (Omalizumab), Pediatrics Vol. 108, No. 2, August 2001 pp.e36.

National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on July 12,2012).

Nelson HS, Weiss ST, Bleecker ER et al. The Salmeterol Multi-center Asthma Research Trial: A comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 129:15-26, 2006.

Saltoun CA. Update on efficacy of allergen immunotherapy for allergic rhinitis and asthma. Allergy Asthma Proc 22:370-380, 2002.

Shah R., Saltoun CA, Acute severe asthma (status asthmaticus) , Allergy Asthma Proc 33: S47-S50, 2012.

Praveen Buddiga, MD, FAAAAI Physician, Allergy, Asthma and Immunology, Founder, Family Allergy Asthma Clinic

Praveen Buddiga, MD, FAAAAI is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: PFIZER.

Muhammad Hassan Bashir, MBBS Physician, Baz Allergy, Asthma and Sinus Center

Muhammad Hassan Bashir, MBBS is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Malik Baz 

Disclosure: Nothing to disclose.

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; Medical Director, Institute for Asthma and Allergy

Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, Association of American Physicians

Disclosure: Nothing to disclose.

Asthma in Older Adults

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