Late-onset asthma common but often underdiagnosed in the elderly
The frequency of asthma incidence in the elderly is similar to that in the younger population, though the condition is often underdiagnosed and thus, undertreated in older people, according to a presentation at the European Academy of Allergy and Clinical Immunology (EAACI) Annual Congress 2016 held in Vienna, Austria.
According to Professor Vibeke Backer, chief respiratory physician at the Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark, one of the reasons behind the underdiagnosis of late-onset asthma is that elderly patients seldom complain about their symptoms as many believe that the shortness of breath experienced is merely an age-related condition.
A study conducted in Colombia involving 5,539 individuals aged 40-93 years found that asthma was underdiagnosed in 79 percent of adults aged ≥64 years. [J Asthma 2015;52:823-830] Living in the capital city (Bogota), being female, having a higher body mass index (BMI) or family history of asthma, and exposure to dust particles, gases or fumes, or indoor wood smoke were among the factors cited for the elevated risk in this age group, said Backer.
In the Copenhagen City Heart Study (CCHS), the frequency of newly-diagnosed asthma was comparable between patients aged <35 (young), 35-64 (middle-aged), and >64 years (old). However, lung function was reduced prior to diagnosis, with a more rapid decline in older adults. [Respir Med 2015;109:821-827]
The elderly patients (in the CCHS) tended to have a higher incidence of shortness of breath, though it was difficult to ascertain whether this was due to asthma or merely being less fit than the younger patients in the study, said Backer. Individuals >64 years had a tendency to develop more obstruction over a 10-year period than those aged 35, she said.
This lower lung function in the elderly was also demonstrated in a previous study where the FEV1/FEV was 65 percent in individuals aged 60-72 years, compared to 80 and 71 percent in individuals aged 18-30 and 31-59 years, respectively (p<0.05). [Resp Med 2011;105:1284-1289]
We need to be more informed about the reduction of lung function and whether it is reduced as a result of age, or if it is specific to asthma patients, said Backer.
The elderly face several changes that could lead to asthma including alterations in the airway physiology and inflammatory profile, higher exposure to environmental noxiae, comorbidities, and deconditioning due to lower fitness levels, said Backer.
Some of the factors that need to be taken into account when managing an elderly asthma patient include the difference in inflammation (neutrophilic rather than eosinophilic) and higher frequency of shortness of breath. It is also important to ensure they are using their inhalers accurately, treat comorbidities (eg, infections and cardiovascular disease which increase the morbidity and mortality risk), encourage smoking cessation, and improve patient education, she said.As the inflammation experienced by these patients is neutrophilic and not eosinophilic, we probably need to manage it differently than we do the eosinophilic cases, said Backer. We also need to be sure that the treatment we have prescribed for these patients is the right one. Due to their lower lung function, these patients may have difficulty using their inhalers, which we need to bear in mind.