Asthma in Older Adults Differential Diagnoses

Updated: Dec 16, 2019
  • Author: Praveen Buddiga, MD, FAAAAI; Chief Editor: Michael A Kaliner, MD  more...
  • Print

Diagnostic Considerations


For diagnosis of COPD, the Global initiative for Obstructive Lung Disease (GOLD) endorses the spirometry criterion of post-BD forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 0.70. This fixed cut-off is susceptible to the risk of overdiagnosing a substantial number of older symptomatic individuals as having COPD, which might contribute to the relative underdiagnosis of asthma in the elderly, particularly females. An alternative approach has been proposed to overcome this problem, whereby the cut-off is based on the lower limit of predicted normal. This cut-off assumes the “usual progressive” lung function decline of COPD is greater than the physiological age-related decline of the FEV1/FVC ratio.

Asthma-COPD Overlap

Older patients frequently present with chronic respiratory symptoms with features of both asthma and COPD and are found to have chronic airflow limitation that is not completely reversible with bronchodilation. The Global Initiative for Asthma (GINA) and the Global Initiative for Obstructive Lung Disease (GOLD) guidelines offer the following clinical descriptions to help distinguish asthma, COPD and asthma-COPD overlap [15] :

Asthma - characterized by chronic airway inflammation defined by a history of respiratory symptoms including wheezing, shortness of breath, chest tightness and cough that vary in intensity and over time. Variable expiratory airflow limitation is also present.

COPD - characterized by persistent respiratory symptoms and airflow limitations due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

Asthma-COPD overlap - characterized by persistent respiratory symptoms and airflow limitations with multiple features associated with asthma and multiple features associated with COPD.

Differential Diagnoses