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The Challenges of Managing Asthma in Older Adults

An interview with Nicola Scichilone, MD, PhD, and Alida Benfante, MD, University of Palermo, Italy

Asthma in older adults is erroneously considered a “rare” disease: perhaps, it should be referred as an “orphan” disease, since the clinical presentations and the functional alterations make asthma in older persons almost a different disease. Certainly, resources should be allocated into research for asthma drugs in older populations, designing specific studies that include this neglected population. 

There is a common misconception hat chronic espiratory symptoms in an individual of advanced age are (almost by definition) to be attributed to chronic obstructive pulmonary isease (COPD), especially in the presence of smoke exposure. The main challenge is to recognize asthma in older individuals and to manage the disease with a multidimensional approach. The complexity and the heterogeneity of the clinical and functional presentations of asthma in this population, together with the higher mortality rates in older individuals with this disease challenge physicians to act quickly and properly.

Annals of Long-Term Care: Clinical Care and Aging (ALTC) spoke with Nicola Scichilone, MD, PhD, and Alida Benfante, MD, from the University of Palermo, Italy, regarding the misconceptions and challenges of managing asthma in older individuals, including their recommendations for optimal treatment. 

 

ALTC: Please discuss the ways in which asthma has been viewed and characterized historically by health care professionals that affect how they diagnose it in older adults now? 

Asthma is among of the most common chronic diseases worldwide1 and will not decrease in prevalence with the world’s growing aging population. However, the disease has been traditionally defined as a disease of younger individuals. In clinical practice, it is common to fall into the trap of attributing respiratory symptoms suggestive of asthma to conditions other than asthma, eg, COPD, when they occur in older adults. The heterogeneity of clinical and functional presentations of asthma in older individuals contributes to this misconception. In addition, the prevalence of asthma in this age range is difficult to establish because of the current absence of universal criteria for the diagnosis in this population. 

Taken ogether, these conditions obviously carry the risk for undertreatment or improper reatment of the disease. Additional factors that contribute to the confusion are the partial loss of reversibility of bronchial obstruction and the poor perception of symptoms by older patients. The incidence of asthma in older adults is difficult to estimate because it may be affected by the recall bias that influences the reliability of self-reported disease; older patients who seem to suffer from late-onset asthma may have cognitive impairment that contributes to mistakes when recalling clinical events. The overall picture is complicated by the confounding influence of multimorbidity and geriatric-associated health conditions. 

The bottom line is that asthma is as frequent in older adults as it is in younger populations. The question is whether the traditional diagnostic algorithm can also be applied in older individuals.

Please explain the significance of the various terms “asthma in older adults,” “senile asthma,” and “geriatric asthma”—the various connotations of these phrases. How have these phrases and ideas impacted medical thought and research? What myths need to be dispelled?

Asthma in older adults describes a condition in which the disease occurs for the first time in this age range. The identification of the age of onset allows providers to distinguish between 2 entities, referred to as “early” and “late” onset asthma. Indeed, asthma that makes its first appearance in advanced age may behave differently from asthma that begins early in life and carries over to old age. Asthma usually starts in childhood and persists throughout the entire life; however, sometimes it may disappear in adulthood and relapse in older age. Early-onset asthma also includes a condition in which the clinical manifestations of asthma occur in old age but recall bias does not allow for properly documented age of onset. The opposite condition is when asthma has a late onset in life (late-onset asthma). The definition of the threshold for “late” onset is fundamental but still an object of debate.2 

The term “senile asthma” refers to the physiological changes of the respiratory system with aging that may influence, to various degrees, the occurrence of airway obstruction or may sometimes mimic the presence of airway obstruction. In this context, it would be more logical to use the phrase “senile lung,” which presents with features of lung hyperinflation due to an homogeneous enlargement of the alveolar airspaces. The senile lung should therefore be distinguished from the emphysematous lung, which implies destruction of the connective tissue of the lung. 

Similar to what we see in other chronic diseases in older adults, asthma cannot be adequately managed in this population without considering the complexity of these individuals. This paradigm has led to the concept of “multidimensional assessment” (MDA), defined as “a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible.”3 MDA is a fundamental tool in geriatric medicine as it allows providers to identify priorities and strategies in the management of these patients. For these reasons, I would suggest using the term “geriatric” asthma instead of “senile” asthma, which confines the disease to the age-related structural and functional changes in the lung, or the more generic “asthma in the adults,” which is only descriptive of the prevalence in this age range. A body of evidence has accumulated in recent years to confirm that the multidimensional management of geriatric asthma should be incorporated in clinical practice 3-5

How do the biological changes associated with aging specifically affect the presentation of asthma in older adults who were diagnosed at an early age? Does the age of onset impact how asthma presentation evolves/worsens (ie, early vs late onset)?   

As mentioned above, early- and late-onset asthma may be regarded almost as 2 different entities, since the inflammatory pattern of the airway and the natural history may differ. First, it should be emphasized that the age of onset can influence the asthma phenotypes; therefore, asthma should be classified according to the age of onset. As an example, asthma starts in childhood and persists into old age, or begins in childhood, disappears in adulthood, and relapses in old age. Asthma may occur for the first time in older adults (ie, after age 65), and this is without any doubt the so-called “late-onset asthma”; however, some studies reported “late” cases of asthma as beginning in adulthood (the cutoff point of 40 years of age is often used in these cases). Finally, the possibility exists that the disease is diagnosed in the most advanced ages as late-onset asthma, but only because the early age of onset is affected by recall bias. 

Early- and late-onset asthma may have important differences both in terms of pathophysiological aspects and prognostic implications. Indeed, the late-onset forms of the disease appear to be more severe and perhaps less atopic. In this context, the immune system undergoes age-related changes that are defined as immunosenescence. The haematopoietic compartment of bone marrow is replaced by fatty adipose tissue with increasing age, with a functional decline in stem cell precursors which, however, seems to occur only under stressing conditions; in basal conditions the absolute numbers of eosinophils and basophils in young vs older persons does not differ. We showed6 that, despite a lower prevalence of atopy documented in older populations, the prevalence of the allergic component remains high in older asthmatics, with potential clinical consequences. For example, the age-related reduction in the production of IgE does not lower the efficacy of a pharmacological approach with anti-IgE in the severe forms of asthma in old age, and an increasing number of older patients is indeed under regular treatment with anti-IgE in real-life settings.  

On the other hand, it should be clear that, although less frequent, the allergic reactions in older adults can have a worse course than in younger individuals. For example, a systemic anaphylactic reaction can have dramatic consequences in older adults in whom the cardiovascular system is not able to effectively compensate. Regardless of age, the assessment of atopy is necessary for a comprehensive evaluation of the chronic respiratory patient, in that, it provides the unique opportunity to act on the environment (removal of allergens) and to modify the natural history of the allergic condition with allergen immunotherapy, which is not precluded by age per se.  

Please discuss asthma prevention methods and effective screening tools for older adults with asthma. Are there any newer, geriatric-specific tools or methods? 

Asthma in older adults needs to be properly recognized, and this is not always an easy task in daily practice. International guidelines and expert consensus do not clearly state whether the traditionally accepted diagnostic process in suspected asthma can also be used in the most advanced ages. From a clinical perspective, the presentation of asthma does not dramatically change with age, although several studies 2,5,7 seem to suggest that older adults more frequently show features of more severe and uncontrolled disease. Asthma in this population still poses some unanswered questions with regard to its pathogenesis and pathophysiological mechanisms, and this is mainly due to the fact that there has been very little original research on this topic. Advanced age per se and the invariably occurrence of comorbidities often represent exclusion criteria in randomized clinical trials (RCTs), thus denying older asthmatics the opportunity to be involved in experimental investigations.8 

Whether the tools used to identify or classify asthma should be modified (or used differently) in older population is therefore a matter of discussion. It has been demonstrated that the vast majority of older adults is capable of performing acceptable and reproducible spirometries as well as carbon monoxide diffusion capacity tests; however, the correct interpretation of the spirometric results in older populations may be challenging because of the age-associated changes in the respiratory system and the lack of reference values for this age ranges. When obtaining a test becomes difficult, specific “age-tailored” tests, such as the measurement of the forced expiratory volume in the first 6 seconds of expiration (FEV6), could be useful, in that, it has the advantage of requiring an easier and faster maneuver. 

The diffusing capacity of the lungs for carbon monoxide, which is supposed to be within normal ranges in asthmatics, is an additional tool to help to exclude diseases other than asthma, such as COPD. The immunosenescence process could contribute to a reduced prevalence of allergic diseases in older populations. However, this matter has not been investigated thoroughly and current guidelines rightly do not include the assessment of the allergic component to distinguish asthma from COPD.

Do you have suggestions for best medications and/or therapies for geriatric asthma (with comorbidities in mind)? Are there some common drug-drug interactions that providers should be aware of? What are some other key considerations clinicians and caregivers should keep in mind as far as asthma management?

Treatment of asthma in the geriatric age group follows recommendations that are extrapolated from observations obtained from RCTs performed in younger populations. Since older age has often represented an exclusion criterion for eligibility in RCTS, most current asthma medications have never been tested in older asthmatics. This may not be a trivial issue, since the pharmacological management of asthma in older individuals should take into account the frequent coexistence of comorbid conditions and the related polypharmacotherapy. Both factors are considered risk factors for adverse drug reactions in older adults; on one hand, comorbidities may interfere with respiratory drugs, and as a consequence, absorption, distribution, metabolism, and excretion of anti-asthmatic medications can be variably affected. In addition, diseases like arthritis or cognitive impairment may negatively impact on the use of the inhaler device with increase in the oral deposition of the drug and decrease in lung deposition, thus reducing the efficacy and increasing local and systemic side effects. On the other hand, the concomitant use of nonrespiratory medications may increase the risk of dangerous interaction with respiratory drugs or may affect the course of the disease. This is the case for β-blockers, frequently prescribed in older individuals, which can elicit bronchoconstriction. From a practical point of view, appropriate monitoring plans should be advocated to scientific societies and regulatory agencies and adopted in clinical practice, and the potential drug-drug interaction should be documented in medical records. Importantly, caregivers should be informed about the potential risks and should be asked to be vigilant and to report any sign of deterioration of clinical conditions.

Are there any educational initiatives or interventions available for health care professionals that may help them and their staff in managing older adults with asthma? What information on asthma should be given to patients to help them manage and be more aware of their asthma symptoms?

The geriatric patient is (almost by definition) characterized by the concomitant occurrence of multiple diseases, whose number increases with ageing. The higher prevalence of comorbidities observed in older adults with asthma does not seem to be associated with worsened asthma control. It is rather the excessive number of medications that indirectly affects asthma control in in these individuals, by worsening the adherence to anti-asthmatic treatment and increasing the risk of drug-drug interactions, with consequent impaired efficacy and safety. 

The above-described features of geriatric asthma call for a different approach to this pathological condition. Based on what has been discussed, the management of asthma in older adults should switch from a disease-oriented to a dysfunction-oriented behavior. In addition to a comprehensive lung function assessment, a multidimensional approach is recommended to establish the complexity of the disease. Finally, patients should be encouraged to visit their physicians on regular basis, and to identify the symptoms’ worsening at early stages. A written plan can help to educate older patients on their asthma and to make the right decisions or, rather, to avoid wrong decisions. 

References 

1. Oraka E, Kim HJ, King ME, Callahan DB. Asthma prevalence among US elderly by age groups: age still matters. J Asthma. 2012;49(6):593-599.

2. Battaglia S, Benfante A, Spatafora M, Scichilone N. Asthma in the elderly: a different disease? Breathe (Sheff). 2016;12(1):18-28.

3. Wardzynska A, Kubsik B, Kowalski ML. Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment. Geriatr Gerontol Int. 2015;15(7):902-909.

4. Scichilone N, Ventura MT, Bonini M, et al. Choosing wisely: practical considerations on treatment efficacy and safety of asthma in the elderly. Clin Mol Allergy.   2015;13(1):7.

5. Hanania NA, King MJ, Braman SS, et al, Asthma in Elderly workshop. Asthma in the elderly: Current understanding and future research needs--a report of a National Institute on Aging (NIA) workshop. J Allergy Clin Immunol. 2011;128(3 suppl):S4-S24.

6. Scichilone N, Augugliaro G, Togias A, Bellia V. Should atopy be assessed in elderly patients with respiratory symptoms suggestive of asthma? Expert Rev Respir Med. 2010;4(5):585-591.

7. Bozek A, Filipowski M, Fischer A, Jarzab J. Characteristics of atopic bronchial asthma in seniors over 80 years of age. Biomed Res Int. 2013:689782.

8. Battaglia S, Basile M, Spatafora M, Scichilone N. Are Asthmatics Enrolled in Randomized Trials Representative of Real-Life Outpatients? Respiration. 2015;89(5): 383-389.


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