Underdiagnosis of asthma in the elderly

doi:10.1016/0007-0971(87)90104-5

British Journal of Diseases of the Chest

Volume 81, 1987, Pages 23-29

https://doi.org/10.1016/0007-0971(87)90104-5 Get rights and content

Abstract

One hundred and ninety-nine elderly men and women were assessed for their pulmonary function and their mental ability. One hundred and twenty-one patients had a PEFR less than 70% of the predicted for their age and height. Reversibility tests showed that 82 patients had 15% or more improvement in their PEFR following 200 μg salbutamol. However, only 6% of the patients were receiving respiratory-related medication.

Further analysis showed that there was no correlation between the patients' age, sex, amounts of sputum production, wheeze, breathlessness, smoking habits, chest expansion, hospitalization, mental function and airway reversibility. ‘Reversible’ patients did, however, have a high incidence of cough and a low pre-test PEFR value. The predominant symptom of ‘reversible’ and ‘non-reversible’ patients was cough.

The study emphasizes the importance of routinely performing lung function tests in elderly patients and the use of reversibility tests to identify reversible airways obstruction. These results suggest that in old age potentially reversible airways obstruction is often overlooked or misdiagnosed.

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Citation Excerpt :
The Tucson epidemiologic study offered the first characterization of asthma in the elderly (AIE) and highlighted the need for further investigation in the group. In the decades that followed, it became apparent that AIE is underdiagnosed and undertreated and that there is a paucity of knowledge regarding many aspects of the disease in this age group.4–11 The need for an assessment of current knowledge became apparent.
Assessing the association of obesity and asthma morbidity in older adults
2016, Annals of Allergy, Asthma and Immunology
Obesity is a robust predictor of poor asthma control in younger adults. Given the high prevalence of asthma and obesity in older Americans, weight reduction could benefit asthma management in this population.
To assess the association between obesity and asthma outcomes among older adults.
We recruited from urban primary care clinics a prospective cohort of nonsmoking individuals with asthma who were 60 years or older without a history of other respiratory diseases. At baseline, body mass index (BMI) measurements were classified as normal (BMI, 18–25), overweight (BMI, 25–30), or obese (BMI, >30). Measures of asthma morbidity (Asthma Control Questionnaire [ACQ], and Mini Asthma Quality of Life Questionnaire [Mini-AQLQ]) and asthma-related resource utilization (inpatient or outpatient) were taken at baseline and at 3- and 12-month interviews. We used generalized estimating equation models to assess associations between obesity and asthma outcomes after controlling for potential confounders.
Of the 437 older adults with asthma in the study, 17% had a normal BMI, 32% were overweight, and 51% were obese. Unadjusted analyses revealed that obesity was associated with lower ACQ scores (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.09–1.31) and poorer Mini-AQLQ scores (OR, 1.21; 95% CI, 1.11–1.33). Adjusted analyses revealed no significant association between obesity and ACQ (OR, 1.05; 95% CI, 0.96–1.15) and Mini-AQLQ (OR, 1.08; 95% CI, 0.99–1.19).
Our study suggests that obesity is not independently associated with worse asthma outcomes in older adults, reflecting potential differences in the mechanisms that link obesity with asthma control in older vs younger populations.
Asthma in the elderly: What we know and what we have yet to know
2014, World Allergy Organization Journal
Citation Excerpt :
Nevertheless, asthma in the elderly (AIE) is still been underdiagnosed and undertreated [5, 21–23]. Notably, AIE may be considered a late-onset disease [14–23]. The French elderly population cohort 3C study, reported that asthma incidence among the elderly was 3.0/1,000 person-year [14].
In the past, asthma was considered mainly as a childhood disease. However, asthma is an important cause of morbidity and mortality in the elderly nowadays. In addition, the burden of asthma is more significant in the elderly than in their younger counterparts, particularly with regard to mortality, hospitalization, medical costs or health-related quality of life. Nevertheless, asthma in the elderly is still been underdiagnosed and undertreated. Therefore, it is an imperative task to recognize our current challenges and to set future directions. This project aims to review the current literature and identify unmet needs in the fields of research and practice for asthma in the elderly. This will enable us to find new research directions, propose new therapeutic strategies, and ultimately improve outcomes for elderly people with asthma. There are data to suggest that asthma in older adults is phenotypically different from young patients, with potential impact on the diagnosis, assessment and management in this population. The diagnosis of AIE in older populations relies on the same clinical findings and diagnostic tests used in younger populations, but the interpretation of the clinical data is more difficult. The challenge today is to encourage new research in AIE but to use the existing knowledge we have to make the diagnosis of AIE, educate the patient, develop a therapeutic approach to control the disease, and ultimately provide a better quality of life to our elderly patients.
Characteristics of allergic sensitization among asthmatic adults older than 55 years: Results from the National health and nutrition examination survey, 2005-2006
2013, Annals of Allergy, Asthma and Immunology
Approximately 60% to 80% of children and young adults with asthma are sensitized to at least one allergen. In contrast, previous studies from specific subpopulations of older patients with asthma suggest that allergic sensitization is significantly lower in this age group. The prevalence and patterns of IgE-mediated sensitization have not been compared among a broad population of younger and older patients with asthma.
To determine the prevalence and patterns of IgE-mediated sensitization among a broad population of younger and older patients with asthma.
Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 to compare IgE-mediated sensitization rates between younger (20-40 years) and older (≥55 years) patients with current asthma. Atopy was defined as a detectable serum IgE to at least 1 allergen in a panel of 19 allergens. The associations among sensitization, current asthma, and asthma control measures (health care use and symptoms) were examined by logistic regression.
In a group of 2,573 patients, either 20 to 40 years of age or 55 years or older, 108 (6.7%) and 43 (4.5%) patients with current asthma were identified, respectively. Allergic sensitization rates among the adults with asthma differed only moderately and not statistically significantly between the age groups; 75.4% of the younger and 65.2% of the older asthmatic patients were sensitized to at least 1 allergen. The association between sensitization and markers of asthma control did not appear to differ among the age groups.
Allergic sensitization in older patients with asthma may be more common than previously reported.
Comparing asthma treatment in elderly versus younger patients
2011, Respiratory Medicine
A randomised 6-month study compared two maintenance doses of budesonide/formoterol (Symbicort^® Turbuhaler^®)^h maintenance and reliever therapy (Symbicort SMART^®), 160/4.5 μg 1 × 2 and 2 × 2, in 8053 asthmatics with symptoms despite treatment with inhaled corticosteroids ± inhaled long-acting β₂-agonists. This analysis compared response to the two treatments in elderly patients, ≥65 years, with that in younger patients. Elderly patients with early- or late-onset asthma were also compared.
Elderly patients had lower post-bronchodilator FEV₁ percentage predicted normal at baseline than younger patients (85.6% vs. 91.0%, respectively). The elderly had more exacerbations and risk of first severe exacerbation was increased by 55.3% (hazard ratio 1.553; 95% confidence interval: 1.249–1.931, p < 0.0001). However, no differences in exacerbations were seen between 1 × 2 or 2 × 2 budesonide/formoterol maintenance and reliever therapy treatment in the elderly. Five-item Asthma Control Questionnaire (ACQ-5) scores improved equally in the two age groups. Changes in mean ACQ-5 scores between 1 × 2 and 2 × 2 were significant in both age groups but not clinically relevant (≥65 years, 0.12; p = 0.018; <65 years, 0.09; p < 0.0001). Elderly patients with early- and late-onset asthma responded equally well to treatment.
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Clinical trial registration: NCT00463866
Age-related changes in immune function: Effect on airway inflammation
2010, Journal of Allergy and Clinical Immunology
Immunosenescence is defined as changes in the innate and adaptive immune response associated with increased age. The clinical consequences of immunosenescence include increased susceptibility to infection, malignancy and autoimmunity, decreased response to vaccination, and impaired wound healing. However, there are several immune alterations that might facilitate persistence of asthma into late adulthood or development of asthma after the age of 50 to 60 years. Asthma in older patients is not uncommon, and this is a growing population as the average lifespan increases. Specific innate changes that might affect severity of asthma in older patients or be involved in the development of late-onset asthma include impaired mucociliary clearance and changes in airway neutrophil, eosinophil, and mast cell numbers and function. Additionally, age-related altered antigen presentation and decreased specific antibody responses might increase the risk of respiratory tract infections. Respiratory tract infections exacerbate asthma in older patients and possibly play a role in the pathogenesis of late-onset asthma. Furthermore, cytokine profiles might be modified with aging, with some investigators suggesting a trend toward T_H2 cytokine expression. This review examines specific innate and adaptive immune responses affected by aging that might affect the inflammatory response in older adults with asthma.

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Original articleUnderdiagnosis of asthma in the elderly

Abstract

Asthma in the elderly

Br Med J

Asthma in the elderly: an epidemeological survey

Br Med J

Asthma in the elderly

Res Clin Forums

Respiratory function tests in older people

Clin Sci

Original article
Underdiagnosis of asthma in the elderly