Asthma in Older Adults 

Updated: Oct 28, 2015
Author: Praveen Buddiga, MD, FAAAAI; Chief Editor: Michael A Kaliner, MD 

Overview

Background

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.

Allergic triggersNon-allergic triggers Allergic triggersNon-allergic triggers

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]

Anatomy

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

Lung tissue normal vs. constricted Lung tissue normal vs. constricted

Pathophysiology

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.

Allergic triggersNon-allergic triggers Allergic triggersNon-allergic triggers

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.

Allergic triggersNon-allergic triggers Allergic triggersNon-allergic triggers

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

Epidemiology

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]

Patient Education

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]

 

Presentation

History

Clinical presentation usually involves an adult patient indicating recurrent episodes of wheezing, chest tightness, shortness of breath, or nocturnal coughing.

Physical Examination

The physical examination may find wheezing, rapid respiratory rate, or in severe cases, accessory respiratory muscle use; however, the physical examination findings may be entirely normal.

 

DDx

 

Workup

Approach Considerations

This usually involves procuring a clinical history of persistent cough or nocturnal cough, wheezing, shortness of breath, or chest tightness triggered by either allergic or nonallergic stimuli. Diagnostic testing may be conducted.

Lab Studies

Spirometry measures the maximal expiratory flow and exhaled volume during a forced expiratory vital capacity maneuver. The test is widely available, reproducible, and highly standardized in terms of performance, methodology, and equipment specifications.

Spirometry is a useful measure of severity of airflow limitation in asthma and is predictive of clinical outcomes. Normal standardized values for spirometry are well established for healthy, multiethnic populations. It is a safe and low-risk procedure that can be performed repeatedly for long-term monitoring.

The prebronchodilator response and postbronchodilator response maneuver involves a baseline spirometric value compared with a postbrochodilator spirometric value (ie, a repeat spirometry 15 min after 2-4 inhalations of albuterol). A measurement of forced expiratory volume in one second (FEV1) improvement of 12% or greater from baseline represents the presence of reversible airflow obstruction, which usually means that the patient has asthma.[7, 8] See the image below.

Spirometric data plotPre Bronchodilator FEV1 = 1.7 Spirometric data plotPre Bronchodilator FEV1 = 1.77 L, Post Bronchodilator FEV1 = 3.11 L approximating to 75 % change or airway reversibility.

Peak Expiratory Flow

Peak expiratory flow (PEF) is a measure of maximum instantaneous expiratory flow and is used as an indicator of airway caliber in asthma. The advantage of peak expiratory flow is that the test can be self-administered on a daily basis, and the results can be recorded manually or electronically to attain the day-to-day or intraday variability.[8]

Peak flows may be used to monitor changes in airflow in response to treatment, in relation to exercise or other provocations, or to determine if shortness of breath (or other chest symptoms) is associated with a change in airflow measurement when trying to differentiate the various causes for shortness of breath (ie, cardiac vs pulmonary).

Imaging Studies

Methacholine inhalation challenge provides a measure of airway responsiveness and has been used as one indication of whether a patient has asthma. A negative methacholine finding is a strong indicator that the patient does not have asthma, whereas a positive finding does not mean that the patient does have asthma. Methacholine challenges have proven useful in the evaluation of coughing patients and in evaluating vocal cord dysfunction. The challenge is performed by inhalation of increasing concentrations of methacholine, which is a cholinergic agonist, until the FEV1 falls by 20% or more.[8]

Exercise Challenge

An exercise challenge measures air flow limitation after a maximum exercise test. A decline in FEV1 of 10% or more is a positive result. A positive test result is highly specific for a diagnosis of asthma in children but less so in adults.[8]

An exercise challenge measures air flow limitation after a maximum exercise test. A decline in FEV1 of 10% or more is a positive result. A positive test result is highly specific for a diagnosis of asthma in children but less so in adults.[8]

Isocapnic Hyperventilation Challenge

Isocapnic hyperventilation challenge via the inhalation of cold, dry air induces bronchoconstriction in many people with asthma but is not considered a diagnostic test. Wide application of the test is limited by the lack of standardization.[8]

Mannitol Challenge

The mannitol inhalation challenge is a promising method of assessing airway hyperresponsiveness by imposing an osmotic stress on the airways. It may induce bronchoconstriction by the same mechanism as exercise or isocapnic hyperventilation.[8]

Mannitol is used for the same indications as methacholine but is easier to perform and less dangerous for personnel who may themselves have airway overreactivity.

Other Tests

Allergy skin testing

Adults with asthma often have an allergic trigger; therefore, skin tests are useful to determine the offending triggers. Strategies for allergen avoidance can then be developed, (eg, cat allergy, dust mite allergy).

Chest radiography

A chest radiograph may reveal hyperinflation of the lungs for a diagnosis of asthma. This test may be an important part of the work-up for differential diagnoses of other respiratory diseases.

Sinus CT scanning

A sinus CT scan may reveal evidence of rhinosinusitis or nasal polyposis, which might help with the diagnosis (eg, Samter’s triad asthma, aspirin sensitivity, nasal polyposis).

pH probe evaluation

This is a procedure that involves placing a pH probe attached to a monitor and measuring in real-time the amount of stomach acid that is refluxed within the esophagus. This may establish a diagnosis of gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) disorder as the etiology of chronic cough. GERD is also known to trigger and exacerbate asthma. LPR can cause postnasal drip, throat clearing, cough, and hoarseness. Lifestyle modifications include weight loss, low-fat diet, decreased caffeine and alcohol intake, raising the head of the bed about 6 inches, and avoiding meals 2-3 hours prior to reclining. Medications that reduce gastric acid secretion may also be helpful. Oral steroids may exacerbate GERD symptoms.[9]

 

Treatment

Approach Considerations

Asthma symptoms usually persist despite avoidance measures; therefore, medications are often needed. The goal of treatment is to prevent fatalities, hospitalizations, and emergency room encounters. The long-term control of asthma with reduction of symptoms, maintenance of normal activity levels, prevention of exacerbations, and preservation of pulmonary function are the goals of therapy.

Consultations

Consultations with the following are indicated:

  • Allergist

  • Pulmonologist

  • Otolaryngologist

Long-Term Monitoring

Asthma is chronic medical condition that requires ongoing monitoring to assess its control and to detect early signs of undertreatment or poor adherence to treatment. Good control in the adult population directly impacts physical function, quality of life, and reduces costs by improving the health of older patients with asthma.

 

Medication

Beta2 agonists, rapid-acting

Class Summary

Rapid-acting, inhaled beta2 agonists are indicated for treatment of acute bronchospasm and prevention of exercise-induced asthma. Beta2-receptor activation leads to activation of adenylcyclase and increased intracellular cyclic AMP. This increase in cyclic AMP activates protein kinase A, which in turn inhibits myosin phosphorylation and lowers intracellular ionic calcium concentration, resulting in muscle relaxation.

Albuterol (Proventil HFA, Ventolin HFA, Proair HFA, AccuNeb)

Albuterol sulfate is a racemic salt of albuterol.

Levalbuterol (Xopenex HFA)

Levalbuterol tartrate is the (R)-enantiomer of albuterol.

Pirbuterol (Maxair)

Pirbuterol acetate is a racemic mixture of 2 optically active isomers.

Corticosteroids, Inhalants

Class Summary

Inhaled corticosteroids are the primary maintenance treatment for persistent asthma. These agents decreased the dose or need for oral corticosteroids. Not indicated for relief of acute bronchospasm.

Beclomethasone, inhaled (Qvar)

Available as an inhaled metered-dose aerosol.

Budesonide inhaled (Pulmicort Flexhaler, Pulmicort Respules)

Available as a dry powder metered-dose inhaler or suspension for inhalation.

Ciclesonide inhaled (Alvesco)

Nonhalogenated glucocorticoid available as an inhaled metered dose aerosol.

Flunisolide inhaled (Aerospan)

Fluorinated glucocorticoid available as an inhaled metered dose aerosol.

Fluticasone inhaled (Flovent Diskus, Flovent HFA)

Available as a powder for inhalation contained within the Diskus device or an aerosolized metered-dose inhaler.

Mometasone inhaled (Asmanex Twisthaler)

Available as dry powder inhaler.

Beta2 agonists, long-acting

Class Summary

These agents may be added to a maintenance treatment regimen of inhaled corticosteroids in patients with moderate-to-severe persistent asthma. This drug regimen may allow for a reduced dose of inhaled corticosteroid.

Salmeterol (Serevent Diskus)

Salmeterol xinafoate is a racemic form of the 1-hydroxy-2-naphthoic acid salt of salmeterol. The active component is salmeterol base. Available as a powder for inhalation contained within the Diskus device.

Respiratory Inhalant Combos

Class Summary

Inhalant combinations consisting of a long-acting beta2 agonist plus a corticosteroid may be considered for moderate-to-severe persistent asthma.

Budesonide/formoterol (Symbicort)

Available as a metered dose aerosol.

Mometasone inhaled/formoterol (Dulera)

Available as a metered dose aerosol.

Salmeterol/fluticasone inhaled (Advair Diskus, Advair HFA)

Available as a powder for inhalation contained within the Diskus device. Also available as an aerosolized inhaler.

Vilanterol/fluticasone furoate inhaled (Breo Ellipta)

Indicated for once-daily treatment of asthma for adults not adequately controlled on a long-term asthma control medication (eg, inhaled corticosteroid), or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and a long-acting beta agonist (LABA). Use prescribe strength (25 mcg/100 mcg or 25 mcg/200 mcg per actuation) once daily via oral inhalation. Fluticasone furoate is a corticosteroid with anti-inflammatory activity. Vilanterol is a long-acting beta agonist (LABA) that stimulates intracellular adenyl cyclase (catalyzes the conversion of ATP to cyclic AMP). Increased cyclic AMP levels cause relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity from cells, especially from mast cells.

Corticosteroids, Oral

Class Summary

Because of severe adverse effects with long-term use with systemic corticosteroids, the lowest possible dose should be used to control asthma, and necessary measures (ie, inhaled corticosteroids, additional medications) should be employed to decrease the dose or discontinue the oral corticosteroid.

Prednisone (Sterapred, Sterapred DS, Rayos)

Oral corticosteroid used for severe asthma and acute flairs.

Leukotriene Receptor Antagonists

Class Summary

These agents areselective and competitive receptor antagonists of leukotrienes, which are components of slow-reacting substance of anaphylaxis (SRSA). Cysteinyl leukotriene production and receptor occupation have been correlated with the pathophysiology of asthma, including airway edema, smooth muscle constriction, and altered cellular activity associated with the inflammatory process, which contribute to the signs and symptoms of asthma.

Montelukast (Singulair)

Selectively blocks binding of leukotriene D4 at the CysLT1 receptor. It is indicated for prophylaxis and chronic treatment of asthma, and for prevention of exercise-induced bronchoconstriction.

Zafirlukast (Accolate)

Inhibits bronchoconstriction as competitive receptor antagonist of leukotrienes C4, D4, and E4. It is indicated for prophylaxis and chronic treatment of asthma.

5-Lipoxygenase Inhibitors

Class Summary

These agents inhibit 5-lipoxygenase, the enzyme that catalyzes the formation of leukotrienes from arachidonic acid. Leukotrienes, which are components of slow-reacting substance of anaphylaxis (SRSA), are correlated with the pathophysiology of asthma, including airway edema, smooth muscle constriction, and altered cellular activity associated with the inflammatory process, which contribute to the signs and symptoms of asthma.

Zileuton (Zyflo Filmtab, Zyflo, Zyflo CR)

Inhibits leukotriene B4, C4, D4, and E4 formation. It is indicated for prophylaxis and chronic treatment of asthma.

Monoclonal Antibody

Class Summary

Inhibits IgE binding to mast cells and basophils, thereby limiting the degree of release of allergic mediators.

Omalizumab (Xolair)

Recombinant humanized IgG1-kappa monoclonal antibody. It is indicated for moderate-to-severe persistent asthma in patients with a positive skin test or in vitro reactivity to a perennial aeroallergen and symptoms that are inadequately controlled with inhaled corticosteroids.