An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Abstract

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

Challenges of managing asthma in an elderly population

“…6 Limited progress has been made in this field over the past 10 years. There has been an increase in the use of computed tomography scans of the thorax and measurements of airway resistance by impulse oscillometry in the elderly, 9 but they do not seem to have translated into more prompt and frequent identification of asthma.…”

“…Lower health expectations and declining cognitive impairments may also contribute to poor perception of breathing and underreporting of symptoms that lead to under diagnosis. 6 There has been more progress over the past decade in relation to the pathobiology of asthma in the elderly than to strategies for diagnosis. There has been considerable progress in our understanding of the process of "immunosenescence" 6 and the association of a low -grade, chronic, systemic inflammation with aging, referred to as "inflamm -aging," characterized by increased interleukin (IL) 1b, IL -6, and tumor necrosis factor α.…”

“…6 There has been more progress over the past decade in relation to the pathobiology of asthma in the elderly than to strategies for diagnosis. There has been considerable progress in our understanding of the process of "immunosenescence" 6 and the association of a low -grade, chronic, systemic inflammation with aging, referred to as "inflamm -aging," characterized by increased interleukin (IL) 1b, IL -6, and tumor necrosis factor α. 10 A number of other processes, including telomere shortening, 11 decreased eosinophil degranulation in response to IL -5, 12 increased airway neutrophilia, 13 or decreased numbers of regulatory T cells, 14 may contribute to an altered inflammatory profile in the airways of elderly asthmatics, which may be a significant determinant of responses to various therapeutic interventions.…”

“…Both aging and the duration of asthma (that may be mutually related) could potentially lead to alterations in the structural changes in the airway wall, submucosa, and in the smooth muscle layers leading to remodelling, loss of lung function, and impaired treatment responses; some of these features may resemble chronic obstructive pulmonary disease. 6 The lack of timely and accurate diagnosis and specific immunopathological changes may modulate treatment responses, in addition to the challenges imposed by co morbidities, altered pharmacology and drug metabolism profiles related to aging, drug interactions due to polypharmacy, poor…”

“…A rigorous and methodologically sound process led to an informative document that provided key recommendations on the unique pathophysiological features, challenges with the diagnosis and management, and directions for future research. 6 It has long been recognized that asthma in the elderly population is underperceived, underdiagnosed, and under treated. 7,8 In addition to the physiological effects of aging on lung mechanics, such as a reduction in lung elastic recoil, forced expiratory volume in 1 second to forced vital capacity ratio, and respiratory muscle strength, which affect interpretation of pulmonary function tests, the lack of accurate prediction equations to interpret and identify airflow obstruction,…”