HEALTH NEWS

Asthma in Older Adults Is Often Misdiagnosed and Undertreated

Written by Patrick Keeffe on September 7, 2017

Researchers say doctors need to watch more carefully for asthma in seniors, and older adults need to adopt healthier lifestyles to avoid developing the ailment.

asthma older adults

Asthma can strike people of any age.

But when it happens at an advanced age, the ailment can be severe and relentless.

Elderly asthmatics are more likely to be underdiagnosed and undertreated and at a higher risk for mortality.

These are some of the findings in a recent study on the effects of asthma on older adults conducted at National Jewish Health (NJH) in Colorado.

Dr. Michael Wechsler, a professor of medicine and co-director of the Cohen Family Asthma Institute at NJH, is co-author of the study.

“Asthma has been underdiagnosed in older people because some people with asthma were told they had COPD [chronic obstructive pulmonary disease],” he told Healthline. “The general population is getting older and, as it ages, asthma is still with them. Also, it’s a combination of better diagnosis and the aging of younger people who have asthma. Most people think of asthma as a young person’s disease, so they don’t think of shortness of breath as asthma.”

Dr. Sidney S. Braman, a pulmonologist who also published a recent study online about asthma in older adults, noted in his abstract that, “The older population has seen the greatest increase in the prevalence of current asthma in recent years… Unfortunately, geriatric-specific guidelines are not available for the diagnosis and treatment of asthma. However, with objective monitoring, avoidance of asthma triggers, appropriate pharmacotherapy, and patient education, the disease can be managed successfully.”

Braman is a professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York.

Asthma in older adults

The Centers for Disease Control and Prevention (CDC) reports that nearly 7 percent of people age 65 and older have asthma.

To treat their asthma, people use an inhaled corticosteroid that inhibits the inflammation that causes asthma. It also helps to prevent asthma and improve lung function.

People with asthma also use a bronchodilator to expand bronchial air passages and to ease breathing.

“Asthma is intermittent or persistent,” Wechsler said. “If it’s persistent, it’s either moderate or severe, and the frequency interferes with daily life. If symptoms occur two times a week, the asthma is persistent. If four to five days a week, it’s moderate. If daily, it’s severe.”

Wechsler said physicians gauge the severity of a person’s asthma and treat it accordingly.

“We ask, is a person’s asthma well-controlled based on what I do?” he said. “What is the frequency of exacerbation, or flares of the disease? What is the level of lung function, based on age, sex, gender, race, and height?”

Older people have lungs that are aging and have lower lung function, Wechsler said.

“Their respiratory muscles are weaker from poor nutrition and from comorbidities such as cardiac and kidney disease, which are associated with muscle weakness, and they have less elastic recoil in the chest wall and lungs,” he explained.

Aging also dulls the immune system’s response to inflammation, Wechsler noted. That is a key contributor to asthma.

With a weakened immune response, the body’s ability to battle infections is reduced, which can trigger an asthma attack.

How common is asthma in seniors?

Not everyone agrees that the incidence of asthma in older adults is rising.

“This is likely not true,” Dr. Sameer Mathur, an associate professor in the Division of Allergy and Immunology at the University of Wisconsin-Madison School of Medicine and Public Health, told Healthline.

“It is more likely that it is now being recognized more so than in the past, especially since pulmonary and allergy/asthma physicians have been trying to get this message across,” Mathur said.

“We find that some patients with childhood asthma go into remission, but likely have residual lung changes, and manifest asthma symptoms when they get older,” he added. “There is also a group of patients that develops the onset of asthma when they are older.”

Asthma is also underdiagnosed and undertreated in older adults, Mathur said, because there can be many causes for shortness of breath, including heart disease.

About 10 percent of older patients are considered to have severe asthma and have a high risk of having exacerbations that result in emergency room visits or hospitalizations, he added.

“So, we suspect many physicians are focusing on other, more acutely life-threatening conditions and ignore the possibility of asthma,” Mathur said.

Getting the diagnosis correct

One man in his 60s ended up going to Wechsler’s Cohen Family Asthma Institute at NJH after seeing two physicians who had incorrectly diagnosed him with COPD.

The man had been coughing and wheezing, and became short of breath, Wechsler said. The doctors gave him a rescue inhaler, but they did not treat him for ongoing airway inflammation.

When the man failed to improve, he went to NJH, underwent a series of sophisticated tests, and was correctly diagnosed with asthma.

“To define if a patient has asthma, we do a pulmonary test, spirometry, to determine if there is any airflow obstruction consistent with asthma, and then assess the degree of reversibility,” Wechsler said. “If we see asthmatic symptoms plus airflow reversibility, we can assess the degree of hyper responsiveness. Imaging by CAT scans helps us look for other components. The patient may have sinus disease, reflux, post-nasal drip, or aspiration.”

How to stay healthy as you age

Aging does not occur only at the organ level.

“People become older at the cellular level, too,” Wechsler said. “This is associated with worsening immunity — the lungs respond less well. It’s called immunosenescence, the gradual deterioration of the immune system.”

Increased inflammation also can contribute to the aging process, he said. Older people start having higher levels of cytokines, such as interleukin 1 and 6. (Cytokines are cell signaling molecules that aid in immune responses and stimulate the movement of cells toward sites of inflammation, infection, and trauma.)

People can boost their immune systems as they age.

“We know the detrimental effects of obesity, and that exercise helps,” Wechsler said. “Exercise could be a possibility to help an aging immune system.”

There are no specific methods for boosting the immune system, said Mathur, adding that staying healthy in general is important.

“Maintain a good diet and stay away from obesity,” he said. “We do know that good nutrition, including intake of vitamin D, is important for good immune function. The main interventions to specifically help with managing asthma are the regular use of appropriate inhaler medications, and keeping up with recommended vaccinations, especially yearly flu vaccine and the series of pneumonia vaccines.”

Utilizing technology

New handheld and telemedical devices are making it easier for patients to monitor their asthma.

“There is a handheld spirometer that a patient can use to send information to our clinic,” Wechsler said. “The device is hooked up to the person’s rescue inhaler, and it can tell us whether they overuse the inhaler, and if they take their meds on time. This technology is relatively new and is used mostly in trials. It’s a question of cost.”

Mathur said he and his UW-Madison colleagues do not use any of the available devices as “standard of care” in their clinical practice.

“However, there are many asthma apps for smartphones that provide reminders to use inhalers and assess levels of symptoms to help gauge whether a visit or call to a healthcare provider is recommended,” he said.

Mathur is interested in an app called Propeller. The free download (iPhone, Android) can be used in conjunction with the Propeller Sensor, which turns a rescue emergency inhaler into a “smart” inhaler and tracks its use.

The Propeller Health website states its app helps users manage their asthma and can “reduce attacks by up to 79 percent.”

A patient can send data collected by the sensor to a healthcare provider.

Propeller also sends reminders to use the inhaler, and alerts physicians and family members when asthma symptoms worsen. It can track where and when patients use their inhalers to help prevent overuse, too.

A daily asthma forecast alerts patients to air-quality issues and other asthma triggers. A smart phone’s geolocation services log exactly where patients are when they use the app, which can help determine if certain places or times trigger asthma symptoms.

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