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We read with interest the new British guideline on the management of asthma published recently as a supplement to Thorax.1 The evidence review groups and guideline authors are to be congratulated on the production of a document of exceptional clarity and ease of use. There is no doubt that adherence to the guideline could contribute substantially to the better management of asthma in the majority of adults, including most elderly patients. However, we feel moved to point out the lack of reference to the difficulties of diagnosis and treatment in patients with abnormalities of cognition, praxis, dexterity and executive function, most of whom are elderly with varying degrees of dementia and/or cerebrovascular disease. This is a retrograde step as earlier versions of the asthma guideline referred to some of these issues. We see this as a missed opportunity to improve the detection and management of asthma in this group of patients who are known to have a high level of morbidity from that condition (class 2 evidence), and in whom the asthma mortality curve is not falling (class 1 evidence). Some of the most recent published work in this domain will not have been included in the evidence trawl for the guideline. Nevertheless, there is ample evidence in the literature relating to the quality of clinical information (class 2+ and 3) in such patients, including spirometry (class 2+) and on the issues of inhaler device competence (class 2+ and 3), selection and training (class 2+). There is also class 2+ evidence that elderly subjects are less able than younger subjects to detect changes in airflow resistance, which has implications for reliever therapy at steps 1 and 2 of the guideline. We strongly advocate that future revisions of the guideline should take account of this evidence, probably as a grade C recommendation or good practice point.
We thank Dr Allen and colleagues for raising these issues. As they point out, the difficulties of diagnosis and treatment are mainly features of the co-morbidity which increases with age, not age itself, and we had not felt it desirable or possible to cover all the changes to routine practice which might be required because of the presence of other diseases. We cannot comment on the items of evidence included in their letter since references are not given, except to say that their points seem correct in principle but some of the evidence levels look unrealistic—for example, one of the flaws of the current grading system is that, however good the evidence on something like asthma mortality, it cannot be level 1 evidence since that is possible for randomised controlled trials only. Nonetheless, we agree that general reference to the potential problems in this patient group might be appropriate and we will consider this in the next version of the guideline.
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