Asthma in older adults

doi:10.1016/S0140-6736(10)61087-2

The Lancet

Volume 376, Issue 9743, 4–10 September 2010, Pages 803-813

https://doi.org/10.1016/S0140-6736(10)61087-2 Get rights and content

Summary

Asthma in older people is common and is characterised by underdiagnosis and undertreatment. Ageing is associated with unique issues that modify expression, recognition, and treatment of the disease. In particular, asthma and chronic obstructive pulmonary disease (COPD) both overlap and converge in older people. This concurrence, together with absence of precise diagnostic methods, makes diagnosis complex. A multidimensional assessment that addresses airway problems, comorbidities, risk factors, and management skills will draw attention to key needs for intervention. Increased attention to the complications of asthma and obstructive airway disease in older people is needed, specifically to develop effective systems of care, appropriate clinical practice guidelines, and a research agenda that delivers improved health outcomes.

Introduction

Asthma in older adults is an increasingly serious health issue. The number of older people with asthma will rise in the next 20 years because of the worldwide population trend to enhanced longevity,¹ and the disproportionate increase in individuals aged older than 64 years.¹ Between 20% (UK) and 36% (China) of the population will be older than 64 years by 2030. Furthermore, the children who lived through the asthma epidemic of the 1980s are growing older. These children will be aged 64 years and older by 2030 and will bring their asthma history to this era, which will progressively swell the numbers of older people with the disease.²

Paradoxically, the issues facing older people with asthma are old-fashioned; in an era of declining asthma mortality, with overdiagnosis and overtreatment of asthma occurring in younger adults and children,³ mortality remains high in older adults,⁴ who continue to be underdiagnosed and undertreated for their asthma.⁵ We are ill equipped with evidence about how to treat asthma in older people and how to design systems of care that will optimise health gains in this age group.⁴ Our pathological confusion about the distinction between asthma and chronic obstructive pulmonary disease (COPD) holds back progress in this discipline. Asthma and COPD both overlap and converge in older people,6, 7, 8, 9 and this issue has yet to be adequately addressed in management approaches.10, 11 We will build on recent reviews12, 13 and move ahead by showing an integrated approach to the understanding and management of asthma in older adults.

Section snippets

Definitions

The definition of terms is very important in this specialty, especially since diagnostic confusion has held back research in older people with airway disease and excluded them from clinical trials of potentially effective treatment. The need for a nominalist approach14, 15 has never been greater. Clear and precise definition of diseases allows for recognition and incorporation of the heterogeneity of components that is present in airway diseases in older people.6, 7, 16

The term older adult

Burden of illness

The prevalence of asthma in older adults in high-income countries is between 6% and 10%. Women predominate in the age group of 64–75 years, but asthma prevalence is similar between sexes after age 75 years.⁴ New cases of asthma continue to arise throughout life, and the 5 year age-specific and sex-specific incidence of newly diagnosed asthma in people older than 65 years is estimated at 103 per 100 000.²²

Two-thirds of deaths attributed to asthma occur in people aged 65 years or older,⁴ and more

Maturing and ageing of the respiratory and immune systems

The lung continues to mature until the age of about 20 years in women and 25 years in men, and thereafter ageing is associated with a progressive fall in lung function (figure 1),²⁸ resulting in both airflow obstruction and exercise limitation. Age-related changes¹² lead to increased air trapping and a reduction in chest wall compliance,28, 29 causing an increased work of breathing.28, 29

The force generation of respiratory muscles can become reduced with age because of degenerative changes in

Diagnosis

The diagnosis of asthma is made by elicitation of symptoms and obtainment of objective assessment of variable airflow obstruction. Underdiagnosis of asthma in elderly people remains as big an issue now as it was in the 1980s. About half of elderly people with asthma have not been diagnosed.⁵ The reasons for underdiagnosis of asthma are multifactorial and include reduced perception of symptoms, misattribution of symptoms to other causes,³² and underuse of objective testing such as spirometry.⁵

Quality of care and management

Undertreatment of asthma remains an issue for older people.⁵ In a population sample of 11 868 340 elderly patients,⁵² substantial deviation from recommended guidelines for asthma care was noted, with evidence of undertreatment with inhaled corticosteroids. Results from a study⁵³ of emergency department presentations for asthma showed that most older patients with acute asthma were not using maintenance inhaled corticosteroids.

The evidence base supporting therapeutic decisions in older people

Multidimensional assessment and intervention

Many converging lines of argument suggest that a multidimensional strategy for the management of asthma in older people might be appropriate. Such a strategy consists of asthma and COPD as both separate and overlapping conditions, asthma and COPD phenotypes, comorbidity, older person care, and components of obstructive airway diseases as treatment targets. The care of older patients almost always implies several different dimensions such as pharmacotherapy, and individual rehabilitation and

Asthma management skills

Drug delivery by the inhaled route offers the best efficacy-to-safety ratio for many asthma therapies. However, ineffective inhalation technique remains a substantial problem that contributes to poor symptom control.⁷⁰ The error rate increases with both age and the extent of airflow obstruction.⁷¹ Wieshammer investigated the use of dry powder inhaler devices and found that the frequency of ineffective inhalation because of a device handling error was 10–15% in adults aged 20–40 years, whereas

Smoking

In people with asthma, smoking is a risk factor for accelerated lung function deterioration,⁵⁹ impaired corticosteroid response, and increased mortality.³⁸ Despite this risk, more than 50% of older people with asthma²² have a history of tobacco smoking, either past or present, and 16% of older adults with an obstructive airway disease—COPD or asthma, or both—are present smokers.⁸⁶ Smoking can contribute to misdiagnosis, and lead physicians to diagnose COPD rather than asthma, or to attribute

Comorbidity

Comorbidity both compounds and confounds the management of asthma in older people. The prevalence of comorbidity from chronic disease increases with age. More than 50% of older people aged 65 years or more have at least three comorbidities and a substantial portion have five or more,¹¹ which are often unrecognised and untreated.⁹⁴ Comorbidity is associated with an ageing population, is linked to asthma, and negatively affects health outcomes.12, 48, 95 Some of the common comorbid disorders that

Conclusions

The future care of older people with asthma and obstructive airway disease needs to be based on improved evidence that recognises the multidimensional aspects of ageing, disease concurrence and comorbidity, and patient preferences. Research is needed to define the benefits of phenotyping airway disease in older people, and to assess advances in systems of care as well as using randomised trials to assess the benefits of new and existing therapy across the spectrum of airway disease in older

Search strategy and selection criteria

We searched the Cochrane Library (2005–10) and Medline (2005–10) using the search terms “asthma” in combination with the terms “elderly” or “aging” or “older”. We largely selected publications in the past 5 years, but did not exclude frequently referenced and highly regarded older publications. We also searched the reference lists of articles identified by this search strategy and selected those we judged relevant. Review articles and book chapters are cited to provide readers with more

References (106)

MI Asher et al.
Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross sectional surveys
Lancet
(2006)
PL Enright et al.
Underdiagnosis and undertreatment of asthma in the elderly. Cardiovascular Health Study Research Group
Chest
(1999)
R Beasley et al.
Time to define the disorders of the syndrome of COPD
Lancet
(2009)
JB Soriano et al.
The proportional Venn diagram of obstructive lung disease: two approximations from the United States and the United Kingdom
Chest
(2003)
FE Hargreave et al.
Asthma as a disease concept
Lancet
(2006)
V Bellia et al.
Asthma in the elderly: mortality rate and associated risk factors for mortality
Chest
(2007)
M De Martinis et al.
Inflamm-ageing and lifelong antigenic load as major determinants of ageing rate and longevity
FEBS Lett
(2005)
KC Meyer et al.
Neutrophils and low grade inflammation in the seemingly normal aging human lung
Mech Aging Dev
(1998)
V Bellia et al.
Aging and disability affect misdiagnosis of COPD in elderley asthmatics
Chest
(2003)
S Lehmann et al.
Factors determining performance of bronchodilator reversibility tests in middle-aged and elderly
Respir Med
(2004)

J Travers et al.

External validity of randomized controlled trials in COPD

Respir Med

(2007)

SS Salvi et al.

Chronic obstructive pulmonary disease in non-smokers

Lancet

(2009)

AE Stuck et al.

Comprehensive geriatric assessment: a meta-analysis of controlled trials

Lancet

(1993)

F Lavorini et al.

Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD

Respir Med

(2008)

V Rabell-Santacana et al.

Inhaled drug use in elderly patients and limitations in association with geriatric assessment scores

Arch Bronconeumol

(2008)

A Schneider et al.

Impact of age, health locus of control and psychological co-morbidity on patients' preferences for shared decision making in general practice

Patient Educ Couns

(2006)

PG Gibson et al.

Self-management, autonomy, and quality of life in asthma

Chest

(1995)

R Horne

Compliance, Adherence, and Concordance–Implications for Asthma Treatment

Chest

(2006)

DW Brown et al.

Inpatient smoking-cessation counseling and all-cause mortality among the elderly

Am J Prev Med

(2004)

LP Boulet et al.

Airway inflammation in asthma with incomplete reversibility of airflow obstruction

Respir Med

(2003)

A Oreopoulos et al.

The obesity paradox in the elderly: potential mechanisms and clinical implications

Clin Geriatr Med

(2009)

LG Wood et al.

Dietary factors lead to innate immune activation in asthma

Pharmacol Ther

(2009)

Report of the Second World Assembly on Ageing

(2002)

VP Luks et al.

Confirmation of asthma in an era of overdiagnosis

Eur Respir J

(2010)

Asthma in Australia 2008

(2008)

M Weatherall et al.

Distinct clinical phenotypes of airways disease defined by cluster analysis

Eur Respir J

(2009)

PG Gibson et al.

The overlap syndrome of asthma and COPD: what are its features and how important is it?

Thorax

(2009)

GB Marks et al.