- Short report
- Open Access
Asthma in the elderly patient
© Boulet. 2016
Received: 19 December 2014
Accepted: 14 December 2015
Published: 2 February 2016
Asthma affects a significant proportion of elderly patients, but unfortunately, it is responsible for a high asthma-related morbidity and mortality in this population. This may be related not only to the development of a more severe asthma phenotype compared to younger patients, with more marked airway obstruction and a more neutrophilic type of airway inflammation, but also to the presence of many co-morbid conditions. Furthermore, in older patients, asthma is often under-diagnosed, undertreated and poorly managed. Unfortunately, elderly patients have usually been excluded of clinical trials on asthma and there is an urgent need to perform more research on the optimal management of asthma in this population.
A 72 years old man is seen at the Emergency Department (ED) for a recent onset of dyspnea, cough and wheezing following what seems to be an upper airway viral infection. He had a past medical history of hypertension, benign prostatic hypertrophy and dyslipidemia. He took a diuretic and a statin. Two years ago, he was seen at the ED for what was considered a mild exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and treated with inhaled bronchodilators and an antibiotic but had no measurement of expiratory flows on that occasion. He had stopped this medication due to fear of side effects. On questionnaire, he often had exercise intolerance and occasional symptoms of cough and wheezing at night or if exposed to respiratory irritants. He had a smoking history of about 8 pack/years. On arrival, his forced expiratory volume in 1 s (FEV1) was 45 % of predicted value (p.v.), with a FEV1/ forced vital capacity (FVC) ratio of 55. A few hours after receiving bronchodilators and oral corticosteroids, his FEV1 had improved to 70 % p.v. On discharge, he was offered a short-course of prednisone and started on a short-acting inhaled bronchodilator on demand plus a medium dose of inhaled corticosteroid. One month later, his FEV1 was 96 % p.v.
This case of asthma in an elderly patient, probably exacerbated by a viral respiratory infection illustrates common management problems in these patients such as confusion with chronic obstructive pulmonary disease (COPD) and poor patient report of chronic troublesome symptoms, often attributed to aging. It also shows the need to confirm the degree and reversibility of airway obstruction by objective means to confirm the diagnosis and offer an appropriate treatment. Careful record of symptoms patterns, smoking history, lung function tests and assessment of treatment response helps to assess the patient condition and treatment needs.
Asthma is common and troublesome in the elderly
Asthma is a respiratory disease characterized by variable respiratory symptoms and airway obstruction associated with airway hyperresponsiveness (AHR) [1, 2]. These features are generally attributed to an airway inflammatory process with progressive bronchial remodelling [3, 4].
Some characteristics of asthma in the elderly
Increased morbidity and mortality
Less frequent atopy
Underdiagnosed and undertreated
Asthma control more difficult to achieve
Reduced perception of symptoms
Difficulties to perform pulmonary function tests
Mixed (more neutrophilic airway inflammation)
More severe airway obstruction
Loss of lung elastic recoil – reduced respiratory muscles strength- small airways involvement
Systemic inflammation and immunosenescence
Insufficient understanding of the disease
Memory impairment, hearing loss, poor sight
Poor adhesion to therapy and follow-up
Poor inhaler technique (arthritis, understanding…)
Polypharmacy and increased risk of interactions
Poor nutrition, sedentarity, weight gain
Reduced access to care
How aging affects asthma pathophysiology
The elderly seems to suffer from a more severe phenotype of asthma, more resistant to the treatment, and with poorer outcomes. This remains however to be more adequately documented, as it can possibly change our approach to asthma management in this population. In this regard, aging is associated with a chronic low grade inflammation called inflamm-ageing . Senescence can promote inflammatory (or down-regulate anti-inflammatory) cell genes, leading to a pro-inflammatory status. Since senescent cells have impaired replicative capacity, with time, this induces premature apoptosis or alters cell function.
Other factors may play a role in making asthma worse in the elderly. However little is known for example on the role of hormonal changes, obesity and metabolic changes. In this regard, although incidence of obesity and metabolic syndrome was not higher in postmenopausal asthma patients than controls, Aydin et al. found an impairment of glucose metabolism and altered adipokine levels in asthma patients. How this may affect asthma remains to be studied .
Physiological changes in the aging lung: the “asthma in the elderly phenotype”
Age-related physiological changes may influence the asthma phenotype. We previously showed that airway obstruction was more marked in elderly asthmatics compared with healthy elderly or younger asthmatic subjects . This may be due to the addition of a progressive “physiological” airway obstruction to the changes associated to asthma. The decline in lung function associated with aging is considered to result from a reduction in compliance and elastic recoil of the lung, in addition to a reduction in respiratory muscle strength while closing and residual volumes (RV) increase [20, 21]. Furthermore, the possibility of an increased prevalence of airway hyperresponsiveness (AHR) in the elderly asthmatic compared to younger subjects has been suggested although determinants of such increase in airway response may differ from younger patients [21, 22].
In the elderly, asthma is more neutrophilic than in younger asthmatic patients, whatever the severity of asthma [20, 23]. This may be related to aging itself, to respiratory infections, corticosteroid intake or other factors. A change in microbiome can play a role in this change in airway inflammatory pattern and even contribute to systemic inflammation . Eosinophils are also found but their function seems reduced . Total and specific IgE are reduced and atopy is considered less frequent but it still affects a large proportion of patients over 65 years old [6, 26, 27].
Furthermore, two main sub-phenotypes have been described in regard to asthma in the elderly according to the onset of symptoms . ‘Early-onset’, starting in childhood or early adulthood, and ‘Late-onset’, starting after 40 years old, this last being associated with a faster lung function decline, less reversible airway obstruction and more severe asthma. We however need to know more about these two types of patients in regard to prognosis and to better guide the treatment .
Assessment of asthma
Asthma is under-diagnosed in the aged patient as symptoms, are often underreported or misinterpreted, and asthma is often confounded with other diseases such as COPD and heart failure [5, 6]. Furthermore, a poor perception of asthma has also been reported in this population . Although very old or physically impaired patients may have difficulties to perform lung function tests, those are much useful to assess properly their asthmatic condition. Some elderly patients may have difficulties to perform spirometry due to physical or cognitive limitations. Furthermore, they often have a certain degree of “physiological” irreversible airway obstruction and the results should be interpreted with caution. Indeed, a fixed FEV1/FVC ratio of less than 0.70 can lead to overdiagnosis of airway obstruction due to airway disease. The lower limit of normal values in uncertain in this age group. So, additional findings such as a significant improvement in FEV1 after bronchodilator (12 % and at least 200 ml) may support a diagnosis of asthma. In the presence of normal expiratory flows, a bronchoprovocation test (e.g. methacholine) may be ne necessary. Furthermore, even this is still debated, it has been suggested that airway hyperresponsiveness (AHR) is more common in the elderly but its determinants may be different [30, 31]. In a review of studies looking at AHR according to age, Scichilone et al. suggested that the data supported an increased prevalence of AHR in the elderly . Furthermore, although it would be useful to know more about the determinants of AHR in this population. The most important seems to be a reduced lung function and a history of smoking, while atopy is an independent determinant.
The number of co-morbidities associated with asthma increases with age and some of those conditions, or the medications required to treat these last, can sometimes affect asthma control . Gastro-oesophageal reflux, chronic rhino-sinusitis, obstructive sleep apnoea and heart conditions are common in the elderly [33, 34]. Obesity is common as we gain weight with age, making asthma control more difficult . Asthma drugs, particularly oral corticosteroids, may also affect concomitant conditions such as osteoporosis, cataracts and glaucoma.
Not only could elderly asthmatics who smoke or have a past history of smoking have a change in their asthma phenotype, being more severe and more neutrophilic, but they may have developed the asthma-COPD overlap syndrome (ACOS) [1, 36]. In a study by Milanese et al., more than one-third of elderly asthmatic patients, despite receiving GINA step 3–4 antiasthmatic therapy, had an Asthma Control Test Score ≤19, a quarter experiencing at least one severe asthma exacerbation in the previous year . One third of patients were classified as having ACOS due to the presence of chronic bronchitis and/or CO lung diffusion impairment and this group had poor asthma outcomes. A more recent study by de Marco et al. also showed that subjects with ACOS had an earlier age of asthma onset and the highest hospitalisation rate . These observations may explain the global poorer outcome in elderly but other factors could also play a role.
Treatment of asthma in the elderly
Asthma in the elderly is commonly under-assessed and treatment is often not in keeping with current guidelines [12, 39–43]. The elderly patient may have concerns about the side-effects of the medication, poor inhaler technique or insufficient inspiratory flows, and asthma management can be affected by memory impairment or economic difficulties [6, 12]. Insufficient adherence to therapy is also frequently reported and the above-mentioned problems, in addition to poor access to care, cultural specificities, or other personal characteristics may explain such reduced adherence [40, 41]. It is also possible that the elderly asthmatic is more resistant to therapy either due to a change in asthma inflammatory phenotype or airway functional changes. This remains to be further studied.
As elderly patients were usually excluded from randomized clinical trials on new treatments, there are few data on the optimal management of asthma in this population. It is therefore recommended to use the same guidelines as for the general population, hoping that further research will guide future recommendations [1, 6]. Control of symptoms, optimisation of pulmonary function, and prevention of future risks including exacerbations, while avoiding side-effects of the medication will guide our approach, which should be carefully individualized.
This type of interventions include smoking cessation, influenza and pneumococcal vaccines. Furthermore, environmental control, promotion of active healthy lifestyle, with good dietary habits, and regular exercise should be promoted. Weight loss, in the presence of obesity, may markedly improve asthma but is often difficult to achieve .
Education of the patient and detection of management difficulties are mandatory [44, 45]. It has been demonstrated that with a more aggressive treatment and regular medical review, acute health care use could be reduced and quality of life improved in the elderly asthmatic patient . A multidisciplinary approach has been proposed for this population, taking into account the various aspects of pharmacotherapy, education, psycho-socio-economical problems co-morbid conditions and acute care needs.
As mentioned previously, the approach will be similar to the general population. Beta-blockers, mainly nonselective forms, are commonly used in elderly patients and may result in worsening asthma symptoms. Even topical forms for treatment of glaucoma have been implicated in severe bronchoconstriction .
Rapid-acting β2-agonists should be provided as rescue therapy, on demand, at the minimal dose and frequency. They are usually well tolerated but if they cause tremor or tachycardia, the dose should be reduced while maintenance therapy revised to minimize their need.
As in younger patients, inhaled corticosteroids (ICS) are the mainstay of asthma treatment in the elderly, although they are insufficiently used in this population [1, 40]. If insufficient to control asthma, we should first check inhaler technique, adherence, environmental factors, smoking status and co-morbid conditions. High-dose ICS and oral corticosteroids should be avoided whenever possible but if this is necessary over prolonged time-periods, prevention of bone loss by appropriate therapy is mandatory.
Associations of ICS and long-acting β2-agonists (LABA) such as formoterol or salmeterol are the first choice of treatment if a low-dose ICS is insufficient . These treatments are usually well tolerated but side-effects, particularly if the patient is suffering from heart conditions should be documented. LABA should never be prescribed as monotherapy in asthma while they often are in COPD [1, 48]. Furthermore, budesonide/formoterol maintenance and reliever therapy has been shown to be an effective and well-tolerated treatment in elderly as in younger asthmatic patients .
Leukotriene receptor antagonists such as montelukast are safe in the elderly but we have few data on their usefulness in this group. Anti-cholinergic agents such as tiotropium have interesting properties for the elderly patients as response to this type of agents is well preserved with age particularly when asthma is severe or in the presence of side-effects of LABA .
Monoclonal antibodies such as omalizumab may be useful in severely asthmatic atopic patients whatever the age . Theophylline is now rarely used, but if so, due to its potential for side-effects and risk of drug interactions, particularly in the aged patient, with frequent heart conditions and poly-pharmacy, its effects should be carefully monitored.
• What are the effects of aging on lung and immune system
• Better characterize the phenotype
o Role of microbiome and infections
o Role of environment
o Influence of atopy, smoking, co-morbidities, gender
• What are the consequences of recent vs. long-standing asthma
• Determine what is the optimal management of asthma
• How educate the elderly and develop an effective multidisciplinary approach
• Should drug therapy be better targeted to this population
o How is it different from younger patients?
o What is the response to therapy (short and long-term outcomes)?
Key-messages for the clinician
• Asthma in the elderly should be distinguished from other conditions such as COPD and heart conditions.
• Careful assessment of asthma control and barriers to achievement of such control - particularly adherence to therapy, poor inhaler techniques, influence of co-morbidities and other management deficiencies - should be addressed.
• As we have few data on the optimal management of asthma in this population, current general guidelines should be used.
• A multi-disciplinary approach should be ensured to look at the various global aspects of elderly asthmatic health.
I’m grateful to Sylvie Carette for her help with the preparation of the manuscript.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- GINA. Global initiative for asthma. 2014. www.ginasthma.org. Accessed 22 October 2015.
- Lougheed MD, Lemiere C, Dell SD, Ducharme FM, FitzGerald JM, Leigh R, et al. Canadian Thoracic Society Asthma Management Continuum–2010 Consensus Summary for children six years of age and over, and adults. Can Respir J. 2010;17(1):15–24.PubMedPubMed CentralGoogle Scholar
- Holgate ST. Pathophysiology of asthma: what has our current understanding taught us about new therapeutic approaches? J Allergy Clin Immunol. 2011;128(3):495–505.PubMedView ArticleGoogle Scholar
- Bergeron C, Boulet LP. Structural changes in airway diseases: characteristics, mechanisms, consequences, and pharmacologic modulation. Chest. 2006;129(4):1068–87.PubMedView ArticleGoogle Scholar
- Zureik M, Orehek J. Diagnosis and severity of asthma in the elderly: results of a large survey in 1,485 asthmatics recruited by lung specialists. Respiration. 2002;69(3):223–8.PubMedView ArticleGoogle Scholar
- Hanania NA, King MJ, Braman SS, Saltoun C, Wise RA, Enright P, et al. 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):S4–24.PubMedPubMed CentralView ArticleGoogle Scholar
- CDC. National Health Interview Survey (NHIS) Data. Centers for disease control and prevention. 2012. http://www.cdc.gov/asthma/nhis/2012/data.htm. Accessed 22 October 2015.
- Moorman JE, Mannino DM. Increasing U.S. asthma mortality rates: who is really dying? J Asthma. 2001;38(1):65–71.PubMedView ArticleGoogle Scholar
- Braman SS, Hanania NA. Asthma in older adults. Clin Chest Med. 2007;28(4):685–702.PubMedView ArticleGoogle Scholar
- Burrows B, Barbee RA, Cline MG, Knudson RJ, Lebowitz MD. Characteristics of asthma among elderly adults in a sample of the general population. Chest. 1991;100(4):935–42.PubMedView ArticleGoogle Scholar
- Tsai C-L, Delclos G, Huang J, Hanania N, Camargo C. Age-related differences in asthma outcomes in the United States, 1988–2006. Ann Allergy Immunol. 2013;110:240–6.View ArticleGoogle Scholar
- Stupka E, deShazo R. Asthma in seniors: Part 1. Evidence for underdiagnosis, undertreatment, and increasing morbidity and mortality. Am J Med. 2009;122(1):6–11.PubMedView ArticleGoogle Scholar
- Slavin RG, Haselkorn T, Lee JH, Zheng B, Deniz Y, Wenzel SE. Asthma in older adults: observations from the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) study. Ann Allergy Asthma Immunol. 2006;96(3):406–14.PubMedView ArticleGoogle Scholar
- Diette GB, Krishnan JA, Dominici F, Haponik E, Skinner EA, Steinwachs D, et al. Asthma in older patients: factors associated with hospitalization. Arch Intern Med. 2002;162(10):1123–32.PubMedView ArticleGoogle Scholar
- Braman SS. Growing old with asthma: what are the changes and challenges? Expert Rev Respir Med. 2010;4(2):239–48.PubMedView ArticleGoogle Scholar
- Bellia V, Pedone C, Catalano F, Zito A, Davi E, Palange S, et al. Asthma in the elderly: mortality rate and associated risk factors for mortality. Chest. 2007;132(4):1175–82.PubMedView ArticleGoogle Scholar
- Jones SC, Iverson D, Burns P, Evers U, Caputi P, Morgan S. Asthma and ageing: an end user’s perspective–the perception and problems with the management of asthma in the elderly. Clin Exp Allergy. 2011;41(4):471–81.PubMedView ArticleGoogle Scholar
- Sharma G, Goodwin J. Effect of aging on respiratory system physiology and immunology. Clin Interv Aging. 2006;1(3):253–60.PubMedPubMed CentralView ArticleGoogle Scholar
- Aydin M, Koca C, Ozol D, Uysal S, Yildirim Z, Kavakli HS, et al. Interaction of metabolic syndrome with asthma in postmenopausal women: role of adipokines. Inflammation. 2013;36(6):1232–8.PubMedView ArticleGoogle Scholar
- Ducharme ME, Prince P, Hassan N, Nair P, Boulet LP. Expiratory flows and airway inflammation in elderly asthmatic patients. Respir Med. 2011;105(9):1284–9.PubMedView ArticleGoogle Scholar
- Turner JM, Mead J, Wohl ME. Elasticity of human lungs in relation to age. J Appl Physiol. 1968;25(6):664–71.PubMedGoogle Scholar
- Janssens JP, Pache JC, Nicod LP. Physiological changes in respiratory function associated with ageing. Eur Respir J. 1999;13(1):197–205.PubMedView ArticleGoogle Scholar
- Brooks CR, Gibson PG, Douwes J, Dalen CJ, Simpson JL. Relationship between airway neutrophilia and ageing in asthmatics and non-asthmatics. Respirology. 2013;18(5):857–65.PubMedView ArticleGoogle Scholar
- Chotirmall SH, Burke CM. Aging and the microbiome: implications for asthma in the elderly? Expert Rev Respir Med. 2015;9(2):125–8.PubMedView ArticleGoogle Scholar
- Mathur SK, Schwantes EA, Jarjour NN, Busse WW. Age-related changes in eosinophil function in human subjects. Chest. 2008;133(2):412–9.PubMedPubMed CentralView ArticleGoogle Scholar
- Yanez A, Cho S-H, Soriano J, Rosenwasser L, Rodrigo G, Rabe K, et al. Asthma in the elderly: what we know and what we have yet to know. World Allergy Organ J. 2014;7(1):8.PubMedPubMed CentralView ArticleGoogle Scholar
- Huss K, Naumann PL, Mason PJ, Nanda JP, Huss RW, Smith CM, et al. Asthma severity, atopic status, allergen exposure and quality of life in elderly persons. Ann Allergy Asthma Immunol. 2001;86(5):524–30.PubMedView ArticleGoogle Scholar
- Reed CE. The natural history of asthma in adults: the problem of irreversibility. J Allergy Clin Immunol. 1999;103(4):539–47.PubMedView ArticleGoogle Scholar
- Connolly MJ, Crowley JJ, Charan NB, Nielson CP, Vestal RE. Reduced subjective awareness of bronchoconstriction provoked by methacholine in elderly asthmatic and normal subjects as measured on a simple awareness scale. Thorax. 1992;47(6):410–3.PubMedPubMed CentralView ArticleGoogle Scholar
- Connolly MJ, Kelly C, Walters EH, Hendrick DJ. An assessment of methacholine inhalation tests in elderly asthmatics. Age Ageing. 1988;17(2):123–8.PubMedView ArticleGoogle Scholar
- Hardaker KM, Downie SR, Kermode JA, Farah CS, Brown NJ, Berend N, et al. Predictors of airway hyperresponsiveness differ between old and young patients with asthma. Chest. 2011;139(6):1395–401.PubMedView ArticleGoogle Scholar
- Scichilone N, Messina M, Battaglia F, Catalano Fand Bellia V. Airway hyperresponsiveness in the elderly: prevalence and clinical implications. Eur Respir J. 2005;25:364–75.PubMedView ArticleGoogle Scholar
- Cosio BG AA. Comorbidity: a distinctive feature of elderly respiratory patients. In: Bellia VAIR, editor. Respiratory diseases in the elderly. vol 43. Sheffield, UK: European Respiratory Society Journal; 2009. p. 205–12.View ArticleGoogle Scholar
- Boulet LP, Boulay ME. Asthma-related comorbidities. Expert Rev Respir Med. 2011;5(3):377–93.PubMedView ArticleGoogle Scholar
- Oreopoulos A, Kalantar-Zadeh K, Sharma AM, Fonarow GC. The obesity paradox in the elderly: potential mechanisms and clinical implications. Clin Geriatr Med. 2009;25(4):643–59.PubMedView ArticleGoogle Scholar
- Gibson PG, Simpson JL. The overlap syndrome of asthma and COPD: what are its features and how important is it? Thorax. 2009;64(8):728–35.PubMedView ArticleGoogle Scholar
- Milanese M, Di Marco F, Corsico AG, Rolla G, Sposato B, Chieco-Bianchi F, et al. Asthma control in elderly asthmatics. An Italian observational study. Respir Med. 2014;108(8):1091–9.PubMedView ArticleGoogle Scholar
- de Marco R, Marcon A, Rossi A, Anto JM, Cerveri I, Gislason T, et al. Asthma, COPD and overlap syndrome: a longitudinal study in young European adults. Eur Respir J. 2015;46(3):671–9.PubMedView ArticleGoogle Scholar
- Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010;376(9743):803–13.PubMedView ArticleGoogle Scholar
- Sin DD, Tu JV. Underuse of inhaled steroid therapy in elderly patients with asthma. Chest. 2001;119(3):720–5.PubMedView ArticleGoogle Scholar
- Boulet LP, Vervloet D, Magar Y, Foster JM. Adherence: the goal to control asthma. Clin Chest Med. 2012;33(3):405–17.PubMedView ArticleGoogle Scholar
- Chotirmall SH, Watts M, Branagan P, Donegan CF, Moore A, McElvaney NG. Diagnosis and management of asthma in older adults. J Am Geriatr Soc. 2009;57(5):901–9.PubMedView ArticleGoogle Scholar
- Hartert TV, Togias A, Mellen BG, Mitchel EF, Snowden MS, Griffin MR. Underutilization of controller and rescue medications among older adults with asthma requiring hospital care. J Am Geriatr Soc. 2000;48(6):651–7.PubMedView ArticleGoogle Scholar
- Anderson CJ, Bardana Jr EJ. Asthma in the elderly: the importance of patient education. Compr Ther. 1996;22(6):375–83.PubMedGoogle Scholar
- Goeman D, Jenkins C, Crane M, Paul E, Douglass J. Educational intervention for older people with asthma: A randomised controlled trial. Patient education and counseling. 2013;93:586–95.Google Scholar
- McDonald VM, Simpson JL, Higgins I, Gibson PG. Multidimensional assessment of older people with asthma and COPD: clinical management and health status. Age Ageing. 2011;40(1):42–9.PubMedView ArticleGoogle Scholar
- Dunn TL, Gerber MJ, Shen AS, Fernandez E, Iseman MD, Cherniack RM. The effect of topical ophthalmic instillation of timolol and betaxolol on lung function in asthmatic subjects. Am Rev Respir Dis. 1986;133(2):264–8.PubMedGoogle Scholar
- Devoy MA, Fuller RW, Palmer JB. Are there any detrimental effects of the use of inhaled long-acting beta 2-agonists in the treatment of asthma? Chest. 1995;107(4):1116–24.PubMedView ArticleGoogle Scholar
- Haughney J, Aubier M, Jorgensen L, Ostinelli J, Selroos O, van Schayck CP, et al. Comparing asthma treatment in elderly versus younger patients. Respir Med. 2011;105(6):838–45.PubMedView ArticleGoogle Scholar
- Ullah MI, Newman GB, Saunders KB. Influence of age on response to ipratropium and salbutamol in asthma. Thorax. 1981;36(7):523–9.PubMedPubMed CentralView ArticleGoogle Scholar
- Maykut RJ, Kianifard F, Geba GP. Response of older patients with IgE-mediated asthma to omalizumab: a pooled analysis. J Asthma. 2008;45(3):173–81.PubMedView ArticleGoogle Scholar