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 10% of adults and an estimated 6% of residents aged 65 and older.

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 or 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)

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.

Distinguishing Asthma from COPD

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

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. To help them find resources that can assist them, click on their county of residence at "Local Info" on the home page.

• 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.

• Systemic corticosteriods may aggravate congestive heart failure and lower serum potassium with potentially adverse cardiac effects.

• Corticosteroids in high doses may reduce bone mineral content and may accelerate development of osteoporosis.
  

• Peak expiratory flow (PEF) monitoring can contribute significantly to management. It may also help distinguish asthma symptoms from symptoms of coexisting heart and lung diseases. However, 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. Assistance from a caretaker may be useful.

• 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 counselor.

• 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

Click here to learn when to refer patients to an asthma specialist.                  

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

ELEMENTS OF A FOLLOW-UP OFFICE VISIT FOR ASTHMA

• 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

• 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.

• 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 b₂-agonists.

• 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).  

• 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.

• The clinician should observe the patient’s metered-dose inhaler and other delivery device techniques (discus, turbohaler, etc.) and provide appropriate feedback.  

• The clinician should review the patient’s Asthma Management Plan.  

 Adapted from Considerations for Diagnosing and Managing Asthma in the Elderly, publication no. 96-3662 from the National Institutes of Health, February 1996, National Heart, Lung and Blood Institute